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HomeMy WebLinkAboutVALENCIA, GERALDINECity of Santa Ana Clerk of the Council I �� AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Is the agreement(s) a permanent record? Yes No -/ Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with C1 �TA 1 «P' No. N-2019-083 was completed on (List all amendments. Use space below if needed.) Revised: 1 Q 18-16 U CA- COTC Office Use Only 1H COUNCIL `,'22 mll: T9 and final payment has been made. Department: Phone/Ext.: Signature: C Date: N-2019-083 e`iSURANCE ON FILL' kNORK MAY PROCEED JNTPI.INSU ANCEEXPIDES 15 .� RECREATION SERVICES AGREEMENT DATE: i Z.01g e G9A U % THIS AGREEMENT is made and entered into on this I st day April, 2019 by and between 5t ivta Cr'44-teraldine Valencia ("Provider") and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to provide various fitness classes in its recreation class program. B. Provider represents that she is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that she is knowledgeable in her field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: I. SCOPE OF SERVICES Provider shall perform those services as set forth in Exhibit A to this Agreement. 2. COMPENSATION In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed $25,000.00 annually. Payment to Provider shall be made monthly within thirty (30) days following completion of the last class taught by Provider the prior month. City shall be responsible for collecting all fees from program participants. Provider shall not collect fees but will refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent (30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall commence on July 1, 2019 and end on June 30, 2020 unless terminated earlier in accordance with Section 12 below. The term of this Agreement may be extended by a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider shall, during the entire tern 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 manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider 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. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Provider shall maintain commercial general liability insurance which 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 Provider'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 and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured's provisions. b. Worker's Compensation Insurance. In accordance with California State law, Provider, if Provider has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. The following requirements apply to the insurance to be provided by Provider pursuant to this section: i. Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. iii. Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. iv. Where the amounts or coverage provided by the certificates of insurance provides coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Consultant shall supply City with a fully executed additional insured endorsement. d. If Provider fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to terminate this Agreement. Such termination shall not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Provider agrees to and shall indemnify, defend and hold harness the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terns of or effects arising from this Agreement, to the extent that the injury, damages, just compensation, restitution, judicial or equitable relief is caused by the negligence of the Provider. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. In no case will Provider be required to indemnify or hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligence of the City. 7. CONFLICT OF INTEREST Provider covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 8. FINGERPRINTS AND BACKGROUND CHECK Provider, and any employees, subcontractors or substitutes, shall arrange for and submit their fingerprints for a criminal background check through the Department of Justice through the City's Human Resources Department process. Consultant shall be responsible for all charges associated with fingerprinting. Consultant shall not perform any services pursuant to this Agreement until clearance is received and Consultant is notified by the City's Parks, Recreation and Community Services Department. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by 3 first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax (714)647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 To Provider: Geraldine Valencia 1855 E. Rose Ave., Apt. 9C Orange, CA 92867 Phone: 949-743-4396 Email: gstarsngdem y cnail.com A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set firth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. The parties agree that any terns or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Provider or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 4 11. ASSIGNMENT/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section I I.b. must be given to the City at least thirty (30) days prior to termination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 13. RECORDS Provider shall use attendance sheets generated and supplied by the City to record attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. NON-DISCRIMINATION Provider shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. JURISDICTION —VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further 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. 16. LICENSES Provider shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. 18. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The person(s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. /YII t� �1 Norma Mitre Acting Clerk of the Council [Signature continue on the next page] CITY OF SANTA ANA Kristine Ridge City Manager APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By:t mm H. L Laura Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: m Geraldine Valencia Exhibit A SCOPE OF SERVICES A. Provider shall conduct various G-Stars classes for ages 1 VS yrs. - 17 yrs B. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or term, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. Various G-STARS Classes A fun and active class where children safely learn age -appropriate gymnastics skills, while building important motor skills, strength and coordination, balancing, bouncing, hopping, singing, and dancing. Parent participation is a MUST for the Parent-n-Me class. Uniform is required. A $1 material fee is due on the first day of class. Instructor: Geraldine Valencia Location: Garfield Community Center, 510 N Lacy St. SA., CA. (714) 571-4288 • G-S tars Gymnastics Tumbling classes will consist of monthly sessions, held 1 day per week, 45 minutes per day • G-Stars Parent-n-Me classes will consist of monthly sessions held 1 day per week, 45 minutes per day C. Provider shall provide all materials, supplies, equipment, records and personnel. Provider shall be responsible for clean-up of the facilities and materials and shall ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 5 paid students and no more than 40 students. B. No registration will be accepted after the second meeting of classes. C. If the minimum registration has not been reached by the second class, the class shall be canceled. Provider will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were cancelled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B. Provider may not waive class participation/ registration fees. C. Only registered participants may participate in class. D. Any refimds to participants will be made in accordance with City policy. E. Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2019-06 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Geraldine Valencia TYPE: Gymnastics 940 W. Chapman Suite 103C N-2018-081 DATE(S): 01/0112019-12/31/2019 Orange, CA 92869 LOCATION: Garfield Community Center *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: SEP41028 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2019 EXPIRATION: JANUARY 11 2020 COMMERCIAL GENERAL LIABILITY OCCURRENCEFORM 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/$3,000,000 ❑ $2,000,000/$2,000,000 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 OTIIER ADDITIONAL INSUREDS Goceline Valencia Flor Hernandez 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: WORKERS' COMPENSATI N DECLARATION I Geraldine Valencia hereby affirm under penalty of perjury, the (Name(ritle) following declaration: I certify on behalf of Geraldine Valenria that during the term of my (Censul4nUCompany Name) contract for Recreation Classes 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:�1� By- Name..ti(t�, I \A 1 R Title: Recreation Instructor 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. P Cis N-2018-081 Phone:(949)743-4396 o® CERTIFICATE OF LIABILITY INSURANCE DATE (MmmomvY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER 1 THIS CERTIFICATE DOER 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: Othe certificate holder is an ADDITIONAL INSURED, the policy1 ie moat have ADDITIONAL INSURED provisions or he 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 coMer rights to the certificate holder in IIaU of sneH AA Lares Insurance Services, Inc. NRMEpC Gahy Chevlre 1163 N. Tustin St. PNCNE 1s 2es B Do - -(�G'-!%g,u1 � �AIC, (714)28B-2873 Orange, CA 92867 A(MMESS: NRI: gchavira@laresinsumnce.com License #: OD99282 INSURERIS) AFFORDING COVERAGE NAII INSURED INBURER A:.._ _ L bertv �t{ -- ai Insurance Geraldine Valencia INSURER e: "— A: GStars Dance and Gymnastics Academy INSURER C: —----------- — 2 W Park Central Ave PISURERD: — Orange, CA 92868-4917 INSURER E. — INDICATED. NOTWITHSTANDING ANY REQUIREMENT, E BEEN ISSUCONED TO THE INSURED NAMED ABOVE FOR THE TERM POLICY CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONSSUCH OR CONDITION ANY THE INSURANCE AFFORDED BY THE POLICIES D SCRSED CT OR OTHER HERE NE 5 SUBJECT POLICIES. PERT( TO TERMS, _OF iSR TO ALL LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THWHICH TYPE OF INSURANCE R POLICYNUMBER - M LICO�YEFk MMIODAnOP A �( COMMERCIAL GENERAL LIABIUtt y BKW60622486 QMIrs _. CLAIMS.MpDE I X I OCCUR 01101/2020 01I0112021 EACHOCCURRENCE -W,7AAOETO-RERfED..—. $ t,a .� MIR EXPIMyoMPeTsgn s — GENLAGGREGATELIMRAPPUESPER PERSONALS ACV INJURY S 1.O X POLICY _ JE,% L... _ LOC GENERALAGGRE_GATE $ 410 OTHER: PRODUCTS-COMP,OPAGG I3 20 AUTOMOBILE LIABILITY BUSIOBss Pro e E ANY AUTO (2 a¢N 81 G UMR tl .._. S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Pa pgraeR) S -- HIRED AUTOSO ONLY AUTOS ONLY AUTOS ONLY BODILY INJURY lPe gcdtlgntl TD9XUf�— E _— _ 11�BPECGNtl --- S UMBRELLA LIAR OCCUR y�EXCESSUAS S -- __CLAIMSMADE' I EACH OCCURRENCE S___ DEC RETENTION AGGREGATE— S WORKERS COMPENSATION S AND EMPLOYERS' LABILITY ANYPROPRIETORIPARTNENEXECUTIVE YIN OFFTCERIMEM9ER EXCWOEDT ATUTE NIA (Ma-daMory In NH) EL EACH ACCIDENT $-- DESCRIPTION OF OPERATONS I LOCATIONS? VEHICLES (ACORD IOI, Adtlillonal R..I. echetlule, may be mmched irmore apRw b roqtl City of Santa Ana, officers, agents, employees, and volunteers are named as additional insuulrerods) on this policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as Is afforded by this policy shall be primary, and any Insurance carried by City shall be excess and noncontributory. & APPROVED City of Santa Ana I U SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS.TION DATE THEREOF, NO nCE BE DELIVERED IN 20 Civic Center Plaza Santa Ana, CA 92702 AUTHOM D RIEPPYESTITIVI ACORD 25 (2018I03) ®1988.2015 ACORD CORPORATION. All rights reserve The ACORD name and logo are registered marks of ACORD Pdnted by GLL on January 15, 2020 at 01:51 PM Wk=. INSURANCE Coverage Is Provided In: West American Insurance Company - a stock company Policy Change Endorsement Policy Number: BKW (21) 60 62 24 86 Policy Period: From 01/01/2020 To 01/01/2021 Endorsement Period: From 01/01/2020 to 01/01/2021 12:01 am Standard Time at Insured Mailing Location Named Insured & Mailing Address Agent Mailing Address & Phone No. GERALDINE VALENCIA DBA: G STARS DANCE AND GYMNASTICS 940 W CHAPMAN AVE STE 103C ORANGE, CA 92868 CHANGES TO POLICY - TRANSACTION 4 2 (714) 288-8000 AA LARES INSURANCE SERVICES INC PO BOX 4817 ORANGE, CA 928634817 This Policy Change Endorsement Results In A Change In The Charges As Follows: Additional Premium Total Additional Charges Certified Acts of Terrorism Additional Charges Description of Change(s) The additional insured form CG2010, Notice of Cancellation form CG8061, and the Primary Non -Contributory form CG2001 are added for the following: City of Santa Ana Risk Management Division - 20 Civic Center Plaza Santa Ana, CA 92702. By RiskM N�& MENT DilivliSiON I 1%/ i' 1 r $79.00 $79.00 $1,00 (Included) Note: This is not a bill Issue Date 01/23/20 Authorized Representative To report a claim, call your Agent or 1-844-325-2467 DS 70 27 01 08 nlni/9n MA714AR hinniimi; Wan Nr APPPNn INSIIRPn rn Pv nn7779 Parr, i nP 17 'OkMutualLiberty . INSURANCE Coverage Is Provided In: West American Insurance Company - a stock company Policy Change Endorsement Named Insured Agent GERALDINE VALENCIA DBA: G STARS DANCE AND GYMNASTICS SUMMARY OF LOCATIONS 0001 940 W Chapman Ave Ste 103C, Orange, CA 92868-2892 POLICY FORMS AND ENDORSEMENTS Policy Number: BKW (21) 60 62 24 86 Policy Period: From 01/01/2020 To 01/01/2021 Endorsement Period: From 01/01/2020 to 01/01/2021 12:01 am Standard Time at Insured Mailing Location (714)288-8000 AA LAKES INSURANCE SERVICES INC This section lists the Fors and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE CG 00 01 04 13 Commercial General Liability Coverage Form - Occurrence CG Ol 67 06 10 California Changes - Public Schools *CG 20 01 04 13 Primary And Noncontributory - Other Insurance Condition *CG 20 1004 13 Additional Insured - Owners, Lessees or Contractors - Scheduled Person or Organization CG 21 0605 14 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data -Related Liability - With Limited Bodily Injury Exception CG 21 47 1207 Employment -Related Practices Exclusion CG 21 67 1204 Fungi or Bacteria Exclusion CG 21 7001 15 Cap on Losses from Certified Acts of Terrorism CG 21 7601 15 Exclusion of Punitive Damages Related to a Certified Act of Terrorism CG 21 8801 15 Conditional Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism (Relating to Disposition of Federal Terrorism Risk Insurance Act) CG 22 30 07 98 Exclusion - Corporal Punishment BE VIEWiskED & APPROVED A 11t Issue Date 01/23/20 Authodzed Representative To report a claim, call your Agent or 1-844-325.2467 DS 70 27 01 08 mmon SM794AR NaMI RR San NrAFPPNn INAIIRFn ropy mm7?c PAU 2 nF 17 Coverage Is Provided In: 1-,1beTty West American Insurance Company - a stock company - Mutual. INSURANCE Policy Change Endorsement Named Insured Policy Number: BHW (21 ) 60 62 24 86 Policy Period: From 01/01/2020 To 01/01/2021 Endorsement Period: From 01/01/2020 to 01/01/2021 12:01 am Standard Time at Insured Mailing Location GERALDINE VALENCIA (714) 288-8000 DBA: G STARS DANCE AND GYMNASTICS AA LAKES INSURANCE SERVICES INC POLICY FORMS AND ENDORSEMENTS - CONTINUED This section lists the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE CG 22 71 04 13 Colleges or Schools (Limited Form) CG 24 26 04 13 Amendment of Insured Contract Definition *CG 80 61 05 11 Amendment of Cancellation Provisions CG 84 99 01 12 Non -Cumulation Of Liability Limits Same Occurrence CG 88 1004 13 Commercial General Liability Extension CG 88 60 12 08 Each Location General Aggregate Limit CG 88 77 12 08 Medical Expense At Your Request Endorsement CG 88 86 12 08 Exclusion - Asbestos Liability CG 88 87 12 08 Exclusion - Lead Liability CG 90 41 01 13 Amendment Of Coverage B Personal And Advertising Injury CP 00 10 04 02 Building and Personal Property Coverage Form CP 00 90 07 88 Commercial Property Conditions CP 01 40 07 06 Exclusion of Loss Due to Virus or Bacteria CP 04 49 12 05 California Changes - Replacement Cost CP 10 30 04 02 Causes of Loss - Special Form CP 10 32 08 08 Water Exclusion Endorsement Issue Date 01/23/20 To report a claim, call your Agent or 1-844-325.2467 R� SW & Mpp SED ByMADI MAR 1 Authorized Representative IDS 70 27 01 08 ntnvnn FM77aRn w Ricin 7911 NrArPPNn INSIIRPn en Pv nn7775 Pats n nP 17 'OkMutualLiberty . INSURANCE Named Insured Coverage Is Provided In: West American Insurance Company - a stock company Policy Change Endorsement GERALDINE VALENCIA DBA: G STARS DANCE AND GYMNASTICS Policy Number: BKW (21) 60 62 24 66 Policy Period: From 01/01/2020 To 01/01/2021 Endorsement Period: From 01/01/2020 to 01/01/2021 12:01 am Standard Time at Insured Mailing Location (714) 288-8000 AA LARES INSURANCE SERVICES INC POLICY FORMS AND ENDORSEMENTS - CONTINUED This section lists the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE CP 72 97 04 02 Equipment Breakdown Enhancement Endorsement - Special Form CP 88 00 07 10 Property Extension Endorsement CP 88 04 03 10 Removal Permit CP 90 59 12 12 Identity Theft Administrative Services and Expense Coverage CP 92 01 05 17 Property Anti -Stacking Endorsement IL 00 17 It 98 Common Policy Conditions IL 00 21 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 01 02 05 05 California Changes - Actual Cash Value IL 01 04 09 07 California Changes IL 02 7009 12 California Changes - Cancellation and NonRenewal IL 04 15 04 98 Protective Safeguards IL 09 35 0702 Exclusion of Certain Computer -Related Losses IL 09 52 01 15 Cap On Losses From Certified Acts Of Terrorism IL 09 96 01 07 Conditional Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism (Relating to Dispostion of Federal Terrorism Risk Insurance Act) LC 87 10 05 00 Punitive or Exemplary Damages Exclusion REVIEWED & MPP ovED gy IiISV MANAG &IL 1 Issue Date 01/23/20 Authorized Representative To report a claim, call your Agent or 1.844-325.2467 DS 70 27 01 08 m n1nn nnR99NIR Nnnn iqR 9Rn NrAFPPNn INRIIRpn enpv nn919R PGGF a nF I) '0� MutualLiberty . INSURANCE Coverage Is Provided In: West American Insurance Company - a stock company Policy Change Endorsement Named Insured Agent GERALDINE VALENCIA DBA: G STARS DANCE AND GYMNASTICS Policy Number: BKW (21) 60 62 24 86 Policy Period: From 01/01/2020 To 01/01/2021 Endorsement Period: From 01/01/2020 to 01/01/2021 12:01 am Standard Time at Insured Mailing Location (714) 288-8000 AA LARES INSURANCE SERVICES INC POLICY FORMS AND ENDORSEMENTS - CONTINUED This section lists the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE J.NP 74 26 04 13 Notice to Policyholder Fully Earned Minimum Premium Endorsements EVREWisk M� & pRpOVED By M 110 Issue Date 01/23/20 Authorized Representative To report a claim, call your Agent or 1.844-325.2467 DS 70 27 01 08 mninn Sna994Pn Nnmi RR 9Rn NraFPPNn INsunrn rnpv nn9799 Parr 5 nr 19 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 avail- able to an additional insured under your poli- cy provided that: (1) The additional insured is a Named In- sured 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 contribu- tion from any other insurance available to the additional Insured. BE IIEWVrisk MI) & APP pOVED µpR 1120 CG 20 01 04 13 0 Insurance Services Office, Inc„ 2012 Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 Organization(s): CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 Location(s) Of Covered Operations in written contract 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 in- jury", '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 oper- ations for the additional insured(s) at the lo- cations) designated above. However: 1. The insurance afforded to such additional Insured only applies to the extent permit- ted by law; and 2. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following addi- tional exclusions apply: This insurance does not apply to 'bodily in- jury" or" property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed 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 or- ganization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. REVIEWED MEENrpOVEOD M 202 �E CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the ap- plicable Limits of Insurance shown in the Dec- larations. REVIEWED & A�PPRpOVEoD By Risk MANAq MA 2020 Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 COMMERCIAL GENERAL LIABILITY CG 80 61 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF CANCELLATION PROVISIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Any term or provision of the Cancellation Conditions of the policy or any endorsement amending or replac- ing such Conditions is amended by the following: A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the person or organization shown in the Schedule below. In no event will the notice to the person or organization scheduled below exceed the notice to the first named insured. B. Our obligation to send notice to the person or organization listed In the Schedule below will terminate at the earlier of the current policy period expiration or when you no longer have a legal or contractual obligation to such person or organization to maintain insurance coverage under a policy which requires that such person or organization be notified in the event of cancellation. SCHEDULE 1. Name: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 2. Address: 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 3. Number of days advance notice: 30 All other terms and conditions of this policy remain unchanged. E HEWWisk N)&m +PpOVoD MA 1 0 - ® 2011 Liberty Mutual Agency Corporation. All rights reserved. CG 80 61 05 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 NP 74 26 04 13 IMPORTANT NOTICE NOTICE TO POLICYHOLDERS This explanation is not a part of your insurance policy, and it does not alter any of its provisions or conditions. No coverage is provided by this notice nor can it be construed to replace any provision in your policy or policies with us, or any forms attached to your policy or policies. The following information only gives a general explanation which may have occurred from your prior (or Did) policy. Read your policy carefully to determine rights, duties, and what is and is not covered. Only the provisions of your policy determine the scope of your insurance protection. This notice has been prepared to provide you with information since one of the forms listed below maybe attached to your policy. Fully Earned and Minimum Premium Endorsements* CG 04 37 - Electronic Data Liability CG 20 03 - Additional Insured - Concessionaires Trading Under Your Name CG 20 10 - Additional Insured - Owners, Lessees Or Contractors - Scheduled Person Or Organization CG 89 79 - Additional Insured - Owners, Lessees Or Contractors - Completed Operations - Scheduled Person Or Organization - Arising Out Of Your Ongoing Operations CG 90 47 - Additional Insured - Owners, Lessees or Contractors - Scheduled Person Or Organization - Caused In Whole Or In Part CG 90 43 - Additional Insured - Owners, Lessees Or Organizations - Scheduled Person Or Organization - Including Primary/Non-Contributory And Waiver Of Subrogation CG 90 44 - Additional Insured - Owners, Lessees Or Contractors - Completed - Operations - Including Primary And Non Contributory And Waiver Of Subrogation CG 20 11 - Additional Insured - Managers Or Lessors Of Premises CG 20 15 - Additional Insured - Vendors CG 20 26 - Additional Insured - Designated Person Or Organization CG 20 28 - Additional Insured - Lessor Of Leased Equipment CG 20 29 - Additional Insured - Grantor Of Franchise CG 20 32 - Additional Insured - Engineers, Architects Or Surveyors Not Engaged By The Named Insured CG 20 34 - Additional Insured - Lessor Of Leased Equipment - Automatic Status When Required In Lease Agreement With You CG 20 37 - Additional Insured - Owners, Lessees Or Contractors - Completed Operations CG 89 80 - Additional Insured - Owners, Lessees Or Contractors - Completed Operations - Arising Out Of Your Work CG 84 56 - Additional Insured - Boat Shows CG 85 83 - Blanket Additional Insured Contractors - Products - Completed Operations CG 85 84 - Additional Insured Contractors Products - Completed Operations CG 86 11 -Additional Insured Automatic Status When Required In Construction Agreement With You - Contractors - Completed Operations CG 89 95 - Additional insured - Automatic Status When Required In Construction Agreement With You - Products/Completed Operations CG 88 83 - Amendment of Other Insurance Condition - Designated Persons or Organizations CG 89 98 - Amendment of Other Insurance Condition One of the above endorsement(s) may be attached to your policy. With the attachment of the endorsement a premium charge has been made along with a fully earned or minimum premium amount which will be retained if the policy is cancelled or issued for less than a one year period. Please refer any questions you may have to your insurance agent. REVIEWED & APPROVED By Risk MANAGEMENT DNIsiON Not applicable in Ohio. A 1 © 2013 Liberty Mutual Insurance NP 74 26 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 CITYOPSANTAANA RISK MANAGEMENT a d4w,, 4HUMAN RESOURCES Wriaging RIAI: mrorr,a+ftgdw ehenp WORKERS' COMPENSATION DECLARATION I, effip=7 ;a \LAQ J? D hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of _ C9kAj Q P 104 that during the term {Consultant/Company Name) of my contract for Recreation Classes 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 3700ofthe Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately, D. Title, Telephone:Print • r 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, REVIEWED & APPROVED By Risk MANAGEMENT DivisiON k0sk Mgmtllnsurance RequirementslWC Declaration 081520I9 Geraldine Valencia 940 W Chapman Ave. Ste., 103C Orange, CA, 92868 October 3, 2019 City of Santa Ana Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Auto Insurance Requirement Release of Liability. Dear City of Santa Ana Risk Management Division: 1, Geraldine Valencia, Gymnastic instructor, hereby release the City of Automobile Liability, I do not uWdrive any vehicle during the course and scope of my course/inshnction class. During the term Jan 1, 2020 through Dec 3, 2020, il3t_ 8019SS. I will be teaching Gymnastic classes at 501 N. Lacy St. Santa Ana, 92701 4Gasti' nstructor REVIEWED & APPROVED By Risk MANACiEMENT DitiSiON 12 1