Loading...
HomeMy WebLinkAboutRUFFIN, DON AND ARLENECity of Santa Ana Clerk of the Council 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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. The agreement with jJ 6 (1 aA/N nk ClE \4 MC ft- 1 Yx— COTC Office Use Only No. N-2019-108 was completed on Oi(I3oJ2020 and final payment has been made. (List all amendments. Use space below if needed.) Department: PKBK Phone/Ext.: fill Signature: C Date: 11 I lil 12021 Revised: 10-18-16 INSURANCE NOT ON FILE WORK MAY KT PROCEED CLERK OF COUNCIL ® DATE: JUN 19 2019 RECREATION SERVICES AGREEMENT N-2019A 08 4i\v%w 0,0Yr I THIS AGREEMENT is made and entered into on this 22nd day of April, 2019 by and between Don Ruffin and Arlene Ruffin ("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 tennis classes in its recreation class program. B. Provider represents that they are able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that they are knowledgeable in their 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: 1. 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 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, ajoint 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 ofinsured'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. M. 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 harmless 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 I 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 terms 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 the 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 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) F.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: Don Ruffin and Arlene Ruffin 28 Grant Irvine, CA 92260 Phone: 949-836-3416 Email: skyvnote mcox.net 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 forth 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 terins 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 terms 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 o, herwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 11 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 1 l .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. [Signatures on next page] IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST ;i Norma Mitre Acting Clerk of the Council .APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Laura Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: CITY OF SANTA ANA KRISTINE RIDGE CITY MANAGER PROVIDER: Lisa udfoff Don Ruffi d Arlene Ruffin utive Director of Parks, Recreation and Community Services Agency Exhibit A SCOPE OF SERVICES A. Provider shall conduct tennis classes for ages 6 and up. 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. INSTRUCTOR: Don / Arlene Ruffin, (949) 678-8658 LOCATION: Neal Machander/Santa Ana High School Tennis Center, 520 W. Walnut St., Santa Ana ADULT BEGINNER'S TENNIS Class is designed for first time players. Learn the basic grips, strokes and scoring. Students must wear non -marling tennis shoes and bring a racquet. Instructor will provide the tennis balls. $15 Material fee payable to instructor 1" day of class. • Adult Beginner's Tennis classes will consist of monthly sessions, held M, W, TH, 1 hour per day. ADVANCE TENNIS Students will work on consistency and control on forehands, backhands, volleys, serves, overheads, lobs, and scoring. Students must wear non -marking tennis shoes and bring a racquet; Instructor will provide the tennis balls. $10 Material fee payable to instructor each month. • Advanced Tennis classes will consist of monthly sessions, held M, W, TH, 2 hours per day. INTERMEDIATE TENNIS Students will work on consistency and control on forehands, backhands, volleys, serves, overheads, lobs, and scoring. Students must wear non -marking tennis shoes and bring a racquet; Instructor will provide the tennis balls. $10 Material fee payable to instructor 1" day of class. • Intermediate Tennis classes will consist of monthly sessions, held M, W, TH, 1% hour per day BEGINNER'S TENNIS Class is designed for first time players. Learn the basic grips, strokes and scoring. Students must wear non -marking tennis shoes and bring a racquet. Instructor will provide the tennis balls. $10 Material fee payable to instructor I" day of class. • Youth Beginner's Tennis classes will consist of monthly sessions, held M, W, TH, I hour, per day PRIVATE & SEMI -PRIVATE TENNIS LESSONS for Youth and Adults Beginners learn basic grips/forehands/backhands/volleys/serves. Intermediate students team overheads, lobs, drop, shots, passing shots, strategy, placement control, and consistency. $10 Material fee payable to instructor each lesson. Registration available at Recreation Centers only. • Youth & Adult Private & Semi -Private Tennis classes will consist of monthly sessions, (schedule with Instructor) 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 1 paid student and no more than 35 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 cancelled. 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. CLASSFEES 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 refunds 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.: 2019-10 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc, in conjunction with City of Santa Ann Apex Insurance Services 20 Civic Center Plaza P. 0. Box 6450 Santa Ann, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Arlene B. Ruffin TYPE: Tennis 28 Grant a © DATE(S): 01/01/2019-12/31/2019 Irvine, CA 92620 LOCATION: Neal Machander Tennis Center, Santn Ana Hiah School *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 1, 2020 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 follovnng 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[nsurance: Medical Payments (Any One Parson) 5,000 MEGL641 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased Q $1,000,00033,000,000 $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, OTHER ADDITIONAL INSUREDS Don Ruffin '�11 CANCELLATION Should the -above described polic�be_cancelled.befgre_the expirgNottdatethereof, notice will to §' a _.�.SGRa�jdanc�th thgpoli_cy_------ _----- __. rovisions. CCAA AUTHORIZED REPRESENTATIVE: DATE ISSUED: December 21 2018 Risk Management FRV N EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2019-10 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: Arlene B. Ruffin TYPE: Tennis 28 Grant DATE(S): 01/01/2019-12131/2019 Irvine, CA 92620 LOCATION: Neal Machander_ Tennis Center, Santa Ana High School *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 1, 2020 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 ❑ $1,000,00053,000,000 ❑ $2,000,00052,000,000 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 Don Ruffin 4LINC'f{LT_ATI0N1i 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: By Risk MANAgEMENT DIVISION U 29 2019 ZA4 �01� FRANCINE R. VILLAREAL Don Ruffin and Arlene Ruffin 28 Grant Irvine, CA 92260 July 17, 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 Divisions: We, Don Ruffin and Arlene Ruffin, Recreation Instructor, hereby release the City of Automobile Liability. We do not use/drive any vehicle during the course and scope of my course/instruction class. During the tfrrq July 1., 2019 through ,Tune 30, 2020, Agreement N-2019-108, we. will be teaching Glasses at Neal Machined/Santa Ana High School Tennis Center, located at: 520 W. Walnut St., Santa Ana, CA. Sincerely, ;Don �rvet5mArlene Ruffin Recreation Instructors REVIEWED & APPROVED By RISk MANAgEMENT DIVISION FRA CANER. VILLAREAL I rime SIR ,w rlL!rw IFturYin h erchy : niffru Imljer Iwcfioty of pMury, the �+r'I w:r� II comrs doll h, IWI o' I )tv & Art -ow kuRlfilm Ih itt Owing thpr term n(M#' A M-N canlmcl kir ---I cirourC 4`Jris�* Instruction _. wer vice% -Aida dic UILY of S u to AIM I v Rl rxrp1. c�l�)>alyh .kJl� I'X'r Ain oil All4- 0UA11ff14.t ILI AS it! 1XCkInIC NO 7CCs [IS lllr ",wk.Crm, ' 4'ompim'1.'L' ion rjw�CI1 C-al 6m. ia, arnl awe dut if I shlouhl 1win1c vat-bim-1 1n t1w -cxmmr—vI1 .1 i4u1 pro!'Worws irf .;Lui;m 17(XI► of rf1,o I,rnbor Oxfo, I s�lml.l f rthwiih cafn jAy ui 01 Ih;.) w pf{ k isioivs- ajiid jma. v i d c pnx-I,Fof ti.i1,tril:cmg' 00mpcnmiim covcrig C. DA S'-ag9 By; X'iil�; � I�a�ru>ti* �'Iw Irl�rCr�l:l�lr _ Al -ef WARNJN(.r: J"A'l.UR1'., 'I0 SrpCU .'�1 0 RK1 RS: C-UNEl ENSATION C0VUtAGE iS USL.AWf Ul- AND S1IA.11w[,fB, E.CT AN If '��1'1..0Y'ER a O CklNflNA1 PCNAI.TIES ANI) CI VIL FINFS UP T ONE .EfU'e DR f wri [OI. SAND DGL.l.ARS (SI00.1 O). IN 1'kIAJ-J I ION I �a l f;f'li r l 1N'F OF u(JI fP1 `, � 1 iiC1'N, DAMAGES AS Pik{: ,VI[)E:I) FORICI SFIL-I IO ?AN► 01:.` I [E.L 130R CODL INTEREST. AND AT1'()RNL- "S' FEL-S. REVIEWED & APPROVED By RISC MANAgEMENT DIVISION U 29 2019 FRANCINE R. VILLAREAL ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/07/2019 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 INSURERS), 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 K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 CONTACT NAME: Mass Merchandising PHONE 1-800-426-2889 Fax 1-260-459-5105 ac No E MAIL°r ADDRESS: info@sportsinsurance-kk.com PRODUCER CUSTOMER ID: INSURERS AFFORDING COVERAGE NAIC If INSURED 2001191574 CP# 2191 Arlene Ruffin 28 Grant ]wine, CA 92620 A Member of the Sports, Leisure & Entertainment RPG INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000447546 RFVIAInM Nil laao FD. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 LTR TYPE OF INSURANCE ADDL INSD BUBR WVD POLICY NUMBER POLICY EFF MWDDNW POLICY EXP MM/DD/YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMSMADE X OCCUR X 68RPG0000006932900 01/01/20 12:01 AM 01/01/21 12:01 AM EACH OCCURRENCE $1,000,000 pAN1AGE TO RENTED PREMISES Ea Occuneece $1,000,000 MED EXP(My one person) $5,000 PERSONAL S ADV INJURYA$5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ PROJECT LOC GENERAL AGGREGATEPOLICY PRODUCTS—COMP/OP AGOOTHER: PROFESSIONAL LIABILITYLEGAL LIAR TO PARTICIPANTS AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlent AUTO OWNED SCHEDULED BODILY INJURY (Per person) BODILY INJURY (Per accident) IANY AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident X Not provided while in Hawaii UMBRELLA OCCUR LIAR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE 11 DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A PER STATIITE OTHER ANY PROPRIETOR/PARTNEW YIN EXECUTIVE OFFICER/MEMBER ❑ EXCLUDED? (Mandatory in NH) If yes, describe under E.L. EACH ACCIDENT E.L. DISEASE— EA EMPLOYEE E.L. DISEASE— POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Instructor of: Tennis Sports instruction conducted at locations that are NOT owned or operated by the instructor. City of Santa Ana, Officers, Agents, Employees and Volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. " This certificate replaces certificate #WO1622111 effective '01/01/20' irrc . I. nvwr=n GANuicLLA I IUN City Of Santa Ana 20 Civic Center Plaza SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Plaza, CA 92701 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH Owner/Manager/Lessor PremiREVIEWED & APPROVED THE POLICY PROVISIONS. of DIVISION BY RISC MANAGEMENTAUTHORIZED REPRESENTATIVE -X � / dt� U 1988-2015 ACORD CORPORATION. All rights reserved. Coverage is only extended to U.S. events and activities. " NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006932900 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) City Of Santa Ana, Officers, Agents, Employees and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Named Insured: Arlene Ruffin CP# 2191 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section It— Who Is An Insured is amended to include as an additional insured the persons) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, 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 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: REVIEWED & AV ROD By Risk MANn�i EB 2 2 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 applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER: 6BRPG0000006932900 INTERLINE IL12011185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change ALimhcr 9 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG00D0006932900 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Arlene Ruffin K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED Common Policy Conditions CHANGES Form Number: SRPG8016 �X Add Form Delete Form Amend Form as Follows: CP# 2191 101�4 'rya Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006932900 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 2.b. is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: Arlene Ruffin Additional Insured: City of Santa Ana, Officers, Agents, Employees, and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Effective:01/01/2020 — 01/01/2021 CP# 2191 RgE IIEWN RiskM D & APPRANAqEmENTpOVEoD F 20 SRPG8016 09/08 POLICY NUMBER: 6BRPG0000006932900 INTERLINE IL12011185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 1 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000006932900 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Arlene Ruffin K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES The following form SRPG8018 is added to the policy. C P#2191 Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006932900 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured. Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply. Additional Insured: City of Santa Ana, Officers, Agents, Employees and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Named Insured: Arlene Ruffin C P#2191 Effective date: 01/01/20 REVIEWED D & APPROVED By F 0 0 SRPG8018 09/08 Arlene Ruffin 28 Grant Irvine, CA. 92620 Oct 30, 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: I, Arlene Ruffin, Tennis instructor, hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term Jan 1, 2020 through Dec 31, 2020, N-2019-108. I Will be teaching Temus at Neal Machander located at: 614 W 1st St, Santa Ana, CA. S'rely, we, Don ftuf n Avlap. 'Rl} I n Tennis Instructor REVIEWED &APPROVED By Risk MANACiEME iON 2 �J / CITY OF SANTA ANA RISK MANAGEMENTa d4,eaee 4HUMAN RESOURCES Managing Risk Bragb PosMw Change WORKERS' COMPENSATION DECLARATION I, Arlene, RUt �l1 /�e171115 1&_d(khereby affirm under penalty of perjury, the (Namelr le) following declaration: I certify on behalf of Il &(l 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 3700 of the Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: Print Title: Signature: Telephone: EL 3I, a0Iq _Arlcne R- In 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 __rF B202 I:IRisk Mgmtllnsurance Requirements) WC Declaration 08152019 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/07/2019 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 INSURERS), 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 K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 CONTACT NAME: Mass Merchandising PHONE 1-800-426-2889 Fax 1-260-459-5105 ac No E MAIL°r ADDRESS: info@sportsinsurance-kk.com PRODUCER CUSTOMER ID: INSURERS AFFORDING COVERAGE NAIC If INSURED 2001191574 CP# 2191 Arlene Ruffin 28 Grant ]wine, CA 92620 A Member of the Sports, Leisure & Entertainment RPG INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000447546 RFVIAInM Nil laao FD. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 LTR TYPE OF INSURANCE ADDL INSD BUBR WVD POLICY NUMBER POLICY EFF MWDDNW POLICY EXP MM/DD/YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMSMADE X OCCUR X 68RPG0000006932900 01/01/20 12:01 AM 01/01/21 12:01 AM EACH OCCURRENCE $1,000,000 pAN1AGE TO RENTED PREMISES Ea Occuneece $1,000,000 MED EXP(My one person) $5,000 PERSONAL S ADV INJURYA$5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ PROJECT LOC GENERAL AGGREGATEPOLICY PRODUCTS—COMP/OP AGOOTHER: PROFESSIONAL LIABILITYLEGAL LIAR TO PARTICIPANTS AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlent AUTO OWNED SCHEDULED BODILY INJURY (Per person) BODILY INJURY (Per accident) IANY AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident X Not provided while in Hawaii UMBRELLA OCCUR LIAR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE 11 DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A PER STATIITE OTHER ANY PROPRIETOR/PARTNEW YIN EXECUTIVE OFFICER/MEMBER ❑ EXCLUDED? (Mandatory in NH) If yes, describe under E.L. EACH ACCIDENT E.L. DISEASE— EA EMPLOYEE E.L. DISEASE— POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Instructor of: Tennis Sports instruction conducted at locations that are NOT owned or operated by the instructor. City of Santa Ana, Officers, Agents, Employees and Volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. " This certificate replaces certificate #WO1622111 effective '01/01/20' irrc . I. nvwr=n GANuicLLA I IUN City Of Santa Ana 20 Civic Center Plaza SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Plaza, CA 92701 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH Owner/Manager/Lessor PremiREVIEWED & APPROVED THE POLICY PROVISIONS. of DIVISION BY RISC MANAGEMENTAUTHORIZED REPRESENTATIVE -X � / dt� U 1988-2015 ACORD CORPORATION. All rights reserved. Coverage is only extended to U.S. events and activities. " NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006932900 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) City Of Santa Ana, Officers, Agents, Employees and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Named Insured: Arlene Ruffin CP# 2191 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section It— Who Is An Insured is amended to include as an additional insured the persons) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, 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 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: REVIEWED & AV ROD By Risk MANn�i EB 2 2 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 applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER: 6BRPG0000006932900 INTERLINE IL12011185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change ALimhcr 9 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG00D0006932900 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Arlene Ruffin K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED Common Policy Conditions CHANGES Form Number: SRPG8016 �X Add Form Delete Form Amend Form as Follows: CP# 2191 101�4 'rya Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006932900 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 2.b. is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: Arlene Ruffin Additional Insured: City of Santa Ana, Officers, Agents, Employees, and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Effective:01/01/2020 — 01/01/2021 CP# 2191 RgE IIEWN RiskM D & APPRANAqEmENTpOVEoD F 20 SRPG8016 09/08 POLICY NUMBER: 6BRPG0000006932900 INTERLINE IL12011185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 1 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000006932900 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Arlene Ruffin K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES The following form SRPG8018 is added to the policy. C P#2191 Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006932900 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured. Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply. Additional Insured: City of Santa Ana, Officers, Agents, Employees and Volunteers 20 Civic Center Plaza Plaza, CA 92701 Named Insured: Arlene Ruffin C P#2191 Effective date: 01/01/20 REVIEWED D & APPROVED By F 0 0 SRPG8018 09/08 Arlene Ruffin 28 Grant Irvine, CA. 92620 Oct 30, 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: I, Arlene Ruffin, Tennis instructor, hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term Jan 1, 2020 through Dec 31, 2020, N-2019-108. I Will be teaching Temus at Neal Machander located at: 614 W 1st St, Santa Ana, CA. S'rely, we, Don ftuf n Avlap. 'Rl} I n Tennis Instructor REVIEWED &APPROVED By Risk MANACiEME iON 2 �J / CITY OF SANTA ANA RISK MANAGEMENTa d4,eaee 4HUMAN RESOURCES Managing Risk Bragb PosMw Change WORKERS' COMPENSATION DECLARATION I, Arlene, RUt �l1 /�e171115 1&_d(khereby affirm under penalty of perjury, the (Namelr le) following declaration: I certify on behalf of Il &(l 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 3700 of the Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: Print Title: Signature: Telephone: EL 3I, a0Iq _Arlcne R- In 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 __rF B202 I:IRisk Mgmtllnsurance Requirements) WC Declaration 08152019