HomeMy WebLinkAboutJOLLY BOUNCERS, INC.City of Santa Ana ......
Clerk of the Council COTC Office Use Only
.. .. .....
.. .... -
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement and all
amendments (if any) are no longer in effect.
C;'Ly of Santa Ana
Note: If your agreement is grant related, please ensure that all grant retention requirements
have been satisfied prior to signing the termination form.
0 42 2021
Is the agreement(s) a permanent record? Yes No)L
Clerk of the C'ouncii
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with —'NQ Wj'� I,- d a=3AQ
No. N-2019423 was completed on 71 JS LobIIC and final payment has been made.
(List all amendments. Use space below if needed.)
Department: PF65A
Phone/Ext.:
Signature:
Date: 116 lain KI
Revised: 10-18-16
INSURANCE NOT ON FILE
WORK MAY 0 PROCEED
CLERK OF COUNCIL
t,
DATEWL 0 S 2019
AMUSEMENT" DEVICE PROVIDER AGREEMENT
THIS AGREEMENT is made and entered into this 261 day of June, 2019, by and between
Jolly Bouncers, Inc., a California corporation ("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 provider to supply inflatable jumpers for the City's Fourth of July
event to be held on July 4, 2019 ("Event").
B. Provider represents that Provider is able and willing to provide such services to the City.
C. In undertaking the performance of this Agreement, Provider represents that it is
knowledgeable in its 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 furnish inflatable jumpers and generator, as more fully described in Exhibit
A attached hereto and incorporated by reference. City grants Provider the right to enter its property
for the purpose of delivery, set-up, and pick-up. The jrunpers shall be set-up and ready for
operation by 4:00 p.m. on July 0 at Centennial Regional Park located at 3000 W. Edinger Avenue
in Santa Ana, California. City staff shall provide final set-up location at Centennial Park to
Provider no later than 24 hours before the event. All equipment provided and set-up for this event
shall be disassembled and removed by Provider at the conclusion of the Event.
2. COMPENSATION
a. City agrees to pay, and Provider agrees to accept as total payment for its services the
amount of Three Thousand One Hundred Two Dollars ($3,102.00). This amount the
base amount of $2,585 identified in Exhibit A, attached hereto and incorporated by
reference, and includes a 20% contingency of $517.00 for use by the City if the City
determines it is necessary to add additional inflatable jumpers of generators.
b. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to the City's accounting procedures.
Payment need not be made for work which fails to meet the standards of performance
set forth in the Recitals which may reasonably be expected by the City.
Page 1 of 6
"EMENI-WIT351
This term of this Agreement shall commence on July 4, 2019 and end on July 5, 2019,
unless terminated earlier in accordance with Section 11 below.
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, 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, including coverage of sexual misconduct. 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 the provisions of 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:
Page 2 of 6
i. Consultant shall maintain all insurance required above in fall 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 forthwith 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 defend, indemnify and hold harmless the City, its officers,
agents, employees, contractors, special counsel, and representatives from liability 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 direct
or indirect 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. The Provider further agrees to indemnify, hold harmless, and pay all costs for the
defense of the City, including fees and costs for special counsel to be selected by the City,
regarding any action by a third party asserting personal injury, damages, just compensation,
restitution, judicial or equitable relief due to personal or property rights arising 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. This indemnification provision No. 6 shall
survive any expiration or termination of this Agreement.
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. 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
Page 3 of 6
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: Jolly Bouncers, Inc.
930 Chambers Lane
Simi Valley, CA 93065
Phone: (805) 995-9802
Fax: (888) 559-7519
Email: iollybouncers(a),vahoo.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 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.
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 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 otherwise, have been made by any party, or anyone
acting on behalf of any parry, which is not embodied herein.
Page 4 of 6
10. 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.
11. TERMINATION
This Agreement may be terminated by the City upon seven (7) 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.
12. RECORDS
Provider shall keep records and invoices in connection with the work to be performed under
this Agreement. Provider shall maintain complete and accurate records with respect to the costs
incurred under this Agreement and any services, expenditures, and disbursements charged to the
City for a minimum period of three (3) years, or for any longer period required by law, from the
date of final payment to City under this Agreement. Provider shall allow inspection of all work,
data, documents, proceedings, and activities related to this Agreement for a period of three (3)
years from the date of final payment to City under this Agreement.
13. 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 in connection with any activities under this Agreement.
14. 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.
15. 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.
Page 5 of 6
16. 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.
17. EXHIBITS
All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in
the body of this Agreement.
18. 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 be 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.
G fly;
rubn
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
j�
By: f llc"ILy 4. Yl,
LAURA ROSSINI
Senior Assistant City Attorney
RECOMMENDED Fr rOVAL:
Ir/
Executive Director of Parks,
Recreation and Community Services Agency
CITY OF SANTA ANA
TINE RIDGE
City Manager
PROVIDER:
JOLLY BOUNCERS, INC
By:
Title:
Page 6 of 6
Law10, 4 Jolly Bouncers, Inc.
�'�� 930 Chambers Lane, Simi Valley, CA 93065 EXHIBIT A
Phone: 805-955-9802 1 Fax: 888-559-7519
Bill To:
CITY OF SANTA ANA
Sonia Batres
Purchasing Division M-16
PO Box 1988
Santa Ana, CA 92702
INVOICE
Invoice #: 35902
Created On: Apr 02, 2019
Start Date: Jul 04, 2019 (Thu)
End Date: Jul 04, 2019 (Thu)
DESCRIPTION
QUANTITY
OF ITEMS
PRICE
PER ITEM
TOTAL PRICE
40 ft Obstacle- Enclosed 2-1.5 Blowers
1
$250,00
$250.00
24 FT Double lane dry
1
500.00
$500.00
Single Bungee Jump
1
$990.00
$990,00
Adrenaline Rush 2
1
$650.00
$650.00
Generator- Double Circuit
3
$65.00
$195.00
Customer Notes / Comments
here are some ideas
QUOTE
helper
want quad bungee
Order Subtotal: $2,585.00
Delivery Charge: $0.00
TOTAL: $2,585.00
Amount Paid: $0.00
Balance Due: $2,585.00
CERTIFICATE OF LIABILITY INSURANCE cATEIMMIoonml
0710312019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rl hts to the certificate holder In lieuof auch endorsement e .
PRODUCER Liberty United Insurance Services, Inc ,a�oMaT�aaCr AX
,.NppE. Sam Mul radyan
704 S Victory Blvd, Suite 204 E.Arn - 8187818888 e,1: 8682658889
Burbank, CA 91502 ADD Eastsamlibertyunitadtnsatranca.amn _____,___
License #: OF89841 INSURE 9 AFFORDING COVERAGE CM
INSURED I iNSUR
Jolly Bouncers, Inc. ----- ------------- —� — --
DBA Allstar Event Rentals IMSUREa0
930 Chambers Lane INBURERD;
Simi Valley, CA 93065 INSURER E: _
COVERAGES CERTIFICATE NUMBER: 00000000-1347414 REVISION NUMBER: 442
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ___
IN$R TYPE OF INSURANCE DLID.NUMBE PYEEE LYE%P LIMITS
LTR
A COMMERCIALDENERALLIABILITY Y N CA000030302.02 04/08/2019 04108/2020 EACHOCCURRENCE $ 1 NO 000
—'�''11 ClAIM6•MADE �� { D TOFF EU
_. __J I A occuR i .pREYrr8E9[,WRIW .� $ 3Q0 000
..
PERSONAL& ADV INJURY $ 1, 000O,QAO
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000
POLICY E JEC ❑ LOG PRPDUCTS C9MPIOPAGG. A--?, 90Q,
TIq�R' � $
AUTOMOBILE LIABILITY. INESING4 }I..' $
ANYAUTO -BODILY INJURY (Per parson) $
OWNED SCHEDULED ._.,__..._..„__._________._.
AUTOS ONLY AUTOS
BODILY INJURY (Per acddent) $
HIRED I I NON FV^ NON -OWNED PRQPE OAbWGE $
f AUTOS ONLY AUTOSONLV
$
UMBRELLALIAB .00CUR EACHOCCURRENCE
EXCESSLIAB CLAIMS MADE AGGREGATE $
E , MTgNI
WORKERS COMPENSATION N[1!TE,„ OFR
AND EMPLOYERS' LIABILITY ---
ANYPROPRIETOWPARTNEtilE%ECUT7yD F NIA EL EACHACCIOENT $
OPFICEOPR1ETEREXCLEFV
(Meadmoryln NHj EJ. J)16EASE, SEA EMPLOYE $
It Ca �bSWMlmdet E RIPTION -PGLICYLIMIT $ OF 'TE etySv E.L, DISEASE
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101. Atltlltlanel Remarks Bchodule, may be aNachad IT more space Is re9ulmtl)
City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured 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.
Awl �o
AA
CERTTFIIHOLDER CANCELLATION..
C�f6
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Santa Ana, its officers, employees, agents, and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
representatives ACCORDANCE WITH THE POLICY PROVISIONS.
20 Civic Center Plaza
Santa Ana, CA 92701 AUTHORaE�D DISPOSED
1 �
..... -... _. ,. -. v-9oc-cvis-i:6CJnr,`CirnwuFih „ul:, ki'r riyiria,TesarveY;..._..
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Printed by SMS on July 03, 2019 at 10:12AM
Policy Number: CA000030302.02
CG 20 26 0413
Effective Dote: 6/13/2019
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARL' FULLY,
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL. LIABILITY COVERAGE PART
SCHEDULE
City of Santa Ana Risk Management
20 Civic Center Plaza
Santa Ana, CA, 92702
A. Section It — Who Is An Insured is amended to include
as an additional insured the person(s) or organization(s)
shown in the Schedule, but only with respect to liability
for "bodily injury", "property damage" or "personal and
advertising injury" caused, in whole or in part, by your
acts or omissions or the aots or omissions of those act-
ing 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 re-
quired by a contract or agreement, the insurance af-
forded to such additional insured will not be broader
than that which you am required by the contract or
agreement to provide for such additional insured.
B. With respect to the insurance afforded to those addi-
tional insureds, the following is added to Section fD —
Limits Of Insurance:
If coverage provided to the additional insured is re-
quired by a contract or agreement, the most we will pay
on behalf of the. additional insured is the amount of in-
surance:
1. Required by tho 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 Lim-
its of Insurance shown in the Declarations,
fl
4 . At .'A°°l
CC 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 ❑
Policy Number: CA000030302.02
Issued Date; 06/25/2019
AD O0 57 0217
Effective Date: 06/13/2019
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CARE, FULLY.
PRIMARY/NONCONTRIBUTING INSURANCE
ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
City of Santa Ana Risk Management
20 Civic Center Plaza,
Santa Ana, CA, 92702
It is agreed that Commercial General Liability Coverage Form CG 00 01 Section IV paragraphs 4.b. and 4.c, do not apply
with respect to other valid and collectible Commercial General Liability insurance, whether primary or excess, available to
the person or organization shown In the Schedule and:
1) Who is an Insured under an Additional Insured -Owners, Lessees or Contractors endorsement attached to this policy;
and
2) Who requires by specific written contract that this insurance Is to be primary andlor non-contributory to other valid
and collectible insurance available to that person or organization.
This endorsement does not change the scope of coverage provided to the person or organization by any Additional Insured
endorsement.
VD "^
t , IV\
����plvt5ictis
RISK ��%itd�
AD 06 57 02 17 Page 1 of 1 0
4r ORICIdR ' CL7MPENSAT1 j�;BCL t R aTIO i
I it WrS hereby affirm under penalty of perjury, the
�drnm>
following declaration:
I certify on behalf of + G that during the term of my
( mlw atrl':mapAnY140-5)
contract for !- ` — services with the City of Santa Ana, I will
not employ any person in any marmer so as to become subject to the workers'
compensation laws of California, and agree that if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions and provide proof of workers' compensation coverage,
DATE:
By: lI 1L1 *a e 4"
Name:1*
Title: d""": `
Telephone: 60 fi-t�..�'-- w"
WARNING: FAILURE TO SECURE wORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL. FINES UP TO ONE IRWORBD THOUSAND DOLLARS ($100,000). IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR
IN SECTION 3706 OF THE LABOR CODB, INTEREST, AND ATTORNEY'S FEES.
���is4lo
et}sib
CERTIFICATE OF LIABILITY INSURANCE
thls cart@taato does not confer fi g hteto ll
�00=R Crescenta Valley Insuranoe
3188 Foothill Blvd. Ste A
La Crescents, CA 91214
Lioense Ih 0091996
waso
Jolly Sounders
4788 Promenade St
Simi Valley, CA 93063.0411
A
CLAIMaMAM 1:1 CCCUR
GRk'�p`A'rjELRnCM. APP�LIM PER:
ile, ( I LOG
rM1��I��TO�S CNLY
AVTECOa ONLY
AIIIITH�ULED
NUTOOMLLYY
UMaftaLl4 LIAa
OCCUR
EMCEae LIAR
19AIMXW
YIN
rota Ana Is named as
endorsement.
may require
(ISM0120MO 106114 020
on
SPEOTTOYMICH THIS
TO ALL THE TERMS,
per
y'
I�
City of Santa Ana
Risk Management Division
20 Civlo Center Plaza
Santa Ana, CA 92702
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ERPiRATWN DATE THEREOF, NOTICE WILL DE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD
_ AGENCY CUSTOMERIO: 00011400
AC® ® VEHICLE SCHEDULE DATEIMMIDDIYYYYI
07/03/2019
AGENCY CARRIER NAIC CODE
Crescenta Valley Insurance California Auto 38342
POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S)
BA040000014964 �05/15/2019 MARK SANDERS
VEHICLEDESCRIPTION
GARAGING 51REET(R qulmd In KY) CITY COUNTY I STATE ZIP
ADDRESS 4758 Promenade StX
_ . Simi Valle _ CA 1 930630411
STATE TERR GVWIGCW CLASS SIC FACTOR SEAT CP RADIUS, FARTHEST TERMINAL COST NEW
_ 10 000_ 1 100 I', § 39,010
USE t COMML FOR HIREY HFCN �� Ar)D'I Nil 9 - t UNORIN9 F (�yf �iER'f� pEOUCTIpLES -' 7CQMPIT $PEC
I ) : COVERAGES �,„I FAULT 1J) MOTOR _ y X REIMU OCC VCQR
PLEASURE RETAIL TOWING IT IGOMPI r -r
I X LIAG MEO PAY S LABOR _ X OTC FG AA ) _ 1ST AMT j § 500
FARM I SERVICE j NU UN1N3 SPEC FTW I GOLL
1V _...L.� c�w.F_'.aosal�� _ osT�.L :.�x�.__._ _ $ -- ._.1$__ 5000OL
DRNET(F �—
C <16 MAPS i6 MILE3+ 'NET VEH � `
I T T P F.'.
VEHU 1 YEAR MAKE RAM TYPE; Trl1Ck VEHICLE TYPE SYM IAGE OTGM5YMj 90M
2 2015 j------ RAM TRUCK 1500 ST N.:1C6RR6FTXFS762581 �P?��sPEc F� coML �a
GARAGING; STREET(Rogn1nd In KY) CITY COUNTY I STATE ZIP
AOOR688 4758 Promenade St [Simi Valley ( CA ,93063 0411
STAIR TERR GVWIGCW CLASS SIC FACTOR �SEATCPI RADIUS I FARTHEST TERMINAL COSTNEW
i0000 _[j ; 100 _ § 29,645
USE T X I COMM'L rOR HIRE 1 ERAGR$L_ FAULTNO —t MOTTRORS . �� F LSP X M OEyOUCTIGLE6 X ACV X 1GOTC2 Tc)OF
PLEASURE i -�j RETAIL 3 I X s TOWING FT X- OTCCOMFO r
{. 1X LwB I IMEDPAY _JRLAHOR X OTC aM L.. STAMT $_ 500
FARM SERVICE } NO UNIN9 ( (SPEC f i FTW GOLL
,FAUL$ 1�FcnsRt _t C�eL 1 _. $ ___ -., s __ 500coL
DRIVE TO i ) 16 —MILES 1fi MILE3 ( Cr YEd -- I
K/ CH GL t i R TOTAL PREM,,
VENft YEAR MAKE DODGE By VEHICLE TYPEm SYM I AGE Io��M SYM
3 120111 MODEL RAM 3500 PICKUP 6 N. 3D73M4CLXBG624553 sPEc oML
1 _[ �—
GARAGING ,STREET Roqui ad In KY) ( CITY COUNTY i STATE 1 ZIP
AOOREss l_4758 Promenade St _ .51 n11 Valley € CA t93063 0411
-- --._ - -
STATE TERR GVWIGCW 4 CLg35 SIC FACTOR SEAT CP RAOIU6 FARTHEST TERMINAL t COST NEW
20,000 L ( 100 _ § 52405
_ .. --
USE COMM'L POR HIRE GHECR Nip` NP UNQWPi9 1 F LSP �iCliF DEUUCTIDLES T V L V{40MPii SPEC
1 GO�ERAGES _ FAUL .... MOiaR ( „1,1 REIME _ _ f� q V, Fll OTC IC OF
PLEASURE RETAIL TOWING RT �+ COME, IFG C
i x LIAD _ MEU PAV 1 & LABOR {y; OTC M _ ST ANIT $ _ 500 _
FARM SERVICE RC^' tR3iNG <f G - _
AS
_i- ��_�� u_ ALA.T UN
i. __ sf L FTw + cou .. 5 4IS _ 5000oL1
ORitFSOHCOL� 15 MILES 1 115 MILES OR i TO ALPRCsM:
VEHMAKE: .NSSAN ,.,, DOtlYPCku VEHICLE TYPE .SYM, AGE: CLSYM:SOM
zii ,, _�
4 2004 mopEL:FRONTIER CREW CAB SC vIN 1N6MD27T84C451907 PP !PEC GOMI
_ _ _ 1 �1 _.
GARAGING I STREET (R qui P,d In KY) CITY ` COUNTY STATE ZIP T
ADORES! i4758 Promenade St [Siml Valle
uc _ T. ,,.._. .ley �...n. __ 93083-0411
STATE TERR GVW lGCW CLg35 SIC FACTOR lEATCP RADIUS FARTHESTTERMINAL 00STNCW
_III
. _...._ .,L-._. �CNEERAGES MOTTOR ..'GGFRLGB COMP, ii}NT____ $EOUCTIaLE& 5 aOTC 10 000 100 § 24
USE COMM'L FOR HIRE F LSP f ICOMPII SPEC
OOVERACES _ RE eMe ACV :OTC t•OF
1
PLEASURE RETAIL LIAR _ MEOPAv FT FG M 3TAMT s _ None
" 3 _ &LABOR (oTc I k
FARM SERVICE 1 N{q�O £ �• UNINS T BPEC FINN DOLL NonecOLl
Drove TO 15 MILES �ffi u1GMILESr INET VEH
1 K45GH00 _ 1 1 C TGiY 1-PREM1
VEHk YEAR (MAKE DODGE _ PICkGi - VEHICLE TYPE BY AGE IOTC SYMj SYM
2 ' 2003 MODE RAM 1500 PICKUP V8 1 D7HA16D53J635509 __j i sPee coML
i_
GARAGING 3TREET(RylrPdi KY) CITY ICOUNrY
STATE ZIP
ADORE33 _ _4758 Promenade St S_iml Valle __ CA _ 93os3 0411
- — — _...
ST TE TERR GVW/GCW CLASS I SIC 1 FACTOR iSEAT CP RADIUS FARTItE9TYEFiMlMA4 COST NEW
10,000 _ 00 _ ' $ 22_,040 _
CHECK, TnOpLNO=-{UNORINS T � RENT bOMPI =gnu+"
USE GOMML FOR HIRE .&C$YErtAGE$'.v� FAULT MOTOR i F {LSPj CMpp}VgTLL16F$ V{ACV, I OTC ` 3CdFPLEASURE RENL V TOWING PT COMPIF0 S�nIIAB MEU PAV &LABOR OTCAA ( SrAMR 5 NOnE
NO= v u§nNR 'cOF s $ Nonecara
FARM SERVICE __. t1FAVLr I X MOTQtiGOhL FPN DOLL OR[VE"fC_ury i <15 MILES[ I15 MILE ttom Pi _ _ v ttltnr nRwu.s
AKr_v The ACORD name and logo are registered marks of AGORb IN
�y/�\ Printed by JAB an July 03. 2019 at 01:29PM lj�j
C
Risk Management Divisior`I
AGENCY CUSTOMER ID: 00011400
_
DATE
rzo®
VEHICLE SCHEDULE
(MMIDDNYVY)
07/03/2019
AGENCY
-
CARRIER
-
NAIL CODE
Crescenta Valley Insurance
Cailfornia Auto
38342
POLICY NUMBER
EFFECTIVE DATE
NAMED INSURED($)
05115/2019
MARK SANDERS
VEHICLE DESCRIPTION
GARAGING STREET (ROquirod In KY) CITY COUNTY STATE ZIP
ADDRESS 4758 Promenade St $Iml Valley.._. 4F USE
_--- CA..a ssoss 0411
STATEI TERR GVWIGCW CLASS SIG FACTOR SEATCP RADIUS i FARTHEST TERMINAL COSTNEW
SE �Go 10 000 __ �100 $ 48 050
-----T- 7CHECK G ADOL NO UNURINS } : RENT V FlOTGh
CO —.MT FORHIRET7 IA DEDUCTIBLES E
�Q¢VMtACES_ i FAULT_ MOTOR I.._... �RCIAna ei AC�. jQ
T PLEASURE RETAIL 1 t TOWING _I FT GDMPI FG
X LIAR MEOPAV BLAEOR XI OTC M S STAMT $ 500
FARM SEHVICL NR f x IlNINS $9FlEC 1 FTW y) COIL GItl�
..—_ fl1Al.�.J. h94T.3±Il... LFAfl. _. ,.., /?� ...,..,. .. ,T .w- .,.� $ 500LOL
a 15 MILEs tEMILER NET Du �" — c�.v, ._.... ......
TtlTA P EMz
VEHq YEAR 'MAKE: FORD 'TYPE; Pickup VEHICLE TYPE SYMIAGEI CO E'OSYMI 90YL
7 12004 MODEL: F250 SUPER DUTY _ IVIN, 1FTNF20L84EA38319 PP saE �GOML _ — _ _-- T
GARAGING I STREET (Roq Trod in KY) CITY COUNTY STATE I ZIP
ADDREss 14758 Promenade St l Slm1 Valley CA., 93063 0411
STATE TERR GVWIGCW LLA99 SO i FACTOR SEAT OF RADIUS ( FARTHESTTERMINAL COSTNEW
��__ 10,000 f 1 t 100_ _ $ 18,959
USE LOMM'LT FOR HIREICNECK T Ap(Sl Ntli T❑❑Nt3AiNSt F LSPEN`i GEDUCTIGLEST l ICOMFIt g$PCi
hO VKNASE9{.. iH`AMIT }._ ealioi ti HLJMR XFAC4t xj OTC 1erOF
LEASURE RETAIL yy } TOWING ') GOMPt 7
LIAR WED PAY 4 81AGOR I, FT A OTC FG 1 M iSTAMT__
yFARM SERVICE mt X ,.1 24 w X cou $ 5000OL
DOW vE act Q 1 i6 MILFS { IS MILER �� YA RC 6f $
VEHq YEAR MAKE BOUT VEHICLE TYPE SYMIAGE CpMpl LOLL
F15PE;�_.... ___._. .,.,...�.� OTC SYM SYM
MODEL _ V LN :. mm PFl41rEC I CCtML _ GARACINGi STREET IR q Y tl KY) �CITY I COUNTY rSTATE ZIP
ADDRESS
LIG .. 1. .. . _ _ ._.—_ __. .... _._. COST NEW
STA HE TERR GVWIGCW CLASS 1 SIC FACTOR SEATCP RADIUS FARTHEST TERMINAL
I
USE COMM4 j FOR f{IREVE�A{$ES I,, FAULR i MOTORft F '-LSP f qp OEDUCTISLE9 jypVj ',Y"OI TCPr ICPOf
{II
j TOWING i---i ,�COMPI i i... I f
I' LEABURC RETAIL I ��. LIAB P MED PAY 8 LAEOR FT pTC FG M 5T ALIT $ _
FARM bERVICE ND ON 3 SPEC I I F1W 'COIL 5 & COL
_, , .XAULT..,X_ MoT RE _- 4 Qr $ _ i- -' --
DRIVE'fit�� --. --
16 MILES 1E MILE9 + NETFEtt.
WORK�9Cj QqL, TWOS TCJAL PREM:S _
VEHN YEAR MAKE IGGUY ) VEHICLE TYPE SYMIAGE C3M T"-9"a`LL
fQTC BYM SYM
$MODEL. IVIN .. ._._..� IPP SPEC] COML
.... .. y..... _ _ ..... .. .... ...._. .... ...
GARAGING qu ra In KY STREET 1Re d CITY COUNTY z STATE ZIP
; )
ADDRESS
STATE TERR GVWIGCW CLASS SIC FACTOR SEATCP RADIUS FARTHEST TERMINAL COSTNEW
_ ( $
USE T COMM'L i FOR HIRE (CHECK T— AW L NOT v UNORINS p �LOp i 11 DEDUCTIBLES ACV} AOMHI SPE@
CQVERAGE9 _ FAULT I, Ya MOTOR REIMU i OTC COi'
PLEAGURE RETAIL j r 1 TOWING
i- FT £ COMPI FG { i
11 LIAR MEU PAY _ & LABOR OTC ) AA _ a ST AMl $ .. _
FARM SERVICE ryGL UNINS SPEC I #COIL
fAU I X; MOTOR . COFL COIL
DRIVE TO 1b MILES] {15 MILFS NETVEH
PORK 434f1001 I ORtCR' i R ^T LL
VEHq YEAR (MAKE TYg- _, _,�„� BODY VEHICLE TV SYMIAGE iv
iQ D$YM SYM
M PP T SPED COME
I �MooeL �YtN
. _ ___ .._,....... ... ®�.. .__._ .�,1..COUN_. STATE
GARAGING I STREET(Raqutradln FSYj CITY COUNTY STATE ZIP
ADDRESS
LIC
STATE TERR GVWIGCW t CLASS i 91C - FACTOR ;SEAT CP� RADIUS FARTHEST TERMINAL t COSTNEW
It
y
USE COMM'1. i FOR I RE i SPECCK bin NT
ICOF
PI EASURE RETAIL F 1 i WIffG FT OTC, FG
fryR MAE MEO PAY S OCR i OTC ( I M 31 AMi $
FARM y(gV/ NtY r y Y UNINb Iyi C ,i IW COIL a S COL
10
name and logo are registered marks of ACORD
Printed by JAB on July 03, 2019 at 01:29PM
POLICY NUMBER: BA040000014064
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
Business Auto Broadening Endorsement
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
I. NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED)
II. EMPLOYEES AS INSUREDS
III. AUTOMATIC ADDITIONAL INSURED
IV. EMPLOYEE HIRED AUTO LIABILITY
V, SUPPLEMENTARY PAYMENTS
VI. FELLOW EMPLOYEE COVERAGE
VII, ADDITIONAL TRANSPORTATION EXPENSE
Vlll. HIRED AUTO PHYSICAL DAMAGE COVERAGE
IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE
X. LOAN/LEASE GAP COVERAGE
XI. GLASS REPAIR —DEDUCTIBLE WAIVER
XI I. TWO OR MORE DEDUCTIBLES
XIII, AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS
XIV, WAIVER OF SUBROGATION
XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS
XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE
XVI I. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT
XVIII, HIRED AUTO —COVERAGE TERRITORY
XIX, BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH
Copyright Z017 Mercury Insurance Services, LLC. All rights reserved
MCA85100817-CA Includes copyrighted materlal of Insurance services Office, Inc„ with Its Permission Pa a I F6
Risk Management Division
POLICY NUMBER: BAD40000014964
BUSINESS AUTO COVERAGE FORM
NEWLY ACQUIRED OR FORMED ENTITY (Broad Form Named Insured)
SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An insured, the following Is added;
d. Any business entity newly acquired or formed by you during the policy period
provided you own 50%or more of the business entity and the business entity Is not
separately Insured for Business Auto Coverage. Coverage Is extended up to a
maximum of 180 days following acquisition or formation of the business entity.
Coverage under this provision is afforded only until the end of the policy period.
Coverage does not apply to an "accident" which occurred before you acquired or
formed the organization.
IL EMPLOYEES AS INSUREDS
SECTION 11 - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following Is added:
e. Any "employee" of yours is an "Insured" while using a covered "auto" you don't
own, hire or borrow in your business or your personal affairs.
III. AUTOMATIC ADDITIONAL INSURED
SECTION II -LIABILITY COVERAGE, A. Coverage, 1, Who Is An Insured, the following Is added;
f, Any person or organization that you are required to include as additional Insured
on the Coverage Form in a written contract or agreement that is signed and
executed by you before the "bodily injury" or "property damage" occurs and that is
in effect during the policy period is an "Insured" for Liability Coverage, but only for
damages to which this insurance applies and only to the extent that person or
organization qualifies as an "insured" underthe Who Is An Insured provision
contained in Section II.
Iv. EMPLOYEE WIRED AUTO LIABILITY
SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following Is added:
g. An "employee" of yours Is an "insured" while operating an "auto" hired or rented
under a contract or agreement In that "employee's" name, with your permission,
while performing duties related to the conduct of your business.
V, SUPPLEMENTARY PAYMENTS
SECTION II —LIABILITY COVERAGE, A, Coverage, 2, Coverage Extensions, a. Supplementary
Payments, Subparagraphs (2) and (4) are replaced by the following;
(2) Up to $8,000 for cost of bail bonds (Including bonds for related traffic law
violations) required because of an "accident" we cover. We are not obligated to
furnish these bonds.
(4) All reasonable expenses incurred by the "insured" at our request, including
actual loss of earnings up to $500 a day because of time off from work.
MCA85100817-CA
Copyright 2017 Mercury Insurance services, I.I.C. All rights reserved,
Includes copyrighted material of Insurance services Office, Inc., with Its Permission
Page 2of6
1:ft /
Management Division
POLICY NUMBER: BA040000014964
VI. FELLOW EMPLOYEE COVERAGE:
SECTION II — LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee
This exclusion does not apply Ifyou have workers' compensatlon Insurance In -force covering all of
your "employees". Coverage is excess over any other collectible insurance.
VII. ADDITIONAL TRANSPORTATION EXPENSE
SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Transportatlor
Expenses, Is replaced with the following:
We will pay up to $50 per day to a maximum of $1000 for temporary transportation
expense incurred by you because of the total theft of a covered "auto" of the private
passenger type, We will pay only for those covered "autos" for which you carry either
Comprehensive or Specified Causes of Loss coverage. We will pay for temporary
transportation expenses Incurred during the period beginning 48 hours after the theft and
ending, regardless of the policy's expiration, when the covered "auto" is returned to use or
we pay for Its "loss". if your business shown In the Declarations is other than an auto
dealership, we will also pay up to $1,000 for reasonable and necessary costs incurred by
you to return a stolen covered auto from the place where it is recovered to its usual
garaging location.
Vill. HIRED AUTO PHYSICAL DAMAGE COVERAGE
SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, the following is
added:
c, If Liability Coverage is provided In this policy on a Symbol 1 or a Symbol 8 basis and
Comprehensive, Specified Causes of Loss, or Collision coverages are provided under
this coverage form for any "auto" you own, then the Physical Damage Coverages
provided are extended to "autos" you hire, subject to the following limit:
(1) The most we will pay for "loss" to any hired "auto" Is $50,000 or Actual
Cash Value or Cost of Repair, whichever is less
(2) $500 deductible will apply to any loss under this coverage extension,
except that no deductible shall apply to "loss" caused by fire or lightning
subject to the above limit and deductible we will provide coverage equal to the
broadest coverage applicable to any covered "auto" you own of similar size and
type. This coverage extension is excess coverage over any other collectible
insurance.
IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE
SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a., Is amended to add the following:
This exclusion does not apply to the accidental discharge of an airbag.
Copyright 2017 Mercury Insurance Services, LLC, All rights reserved,
MCABS100817-CA Includes copyrighted material of Insurance Services 0fflce, Inc, with its Permission Page 3 of 6
EWER BY'
Risk Management Division
POLICY NUMBER: BA040000014084
X. LOAN/LEASE GAP COVERAGE
SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added;
4. In the event of a "total loss" to a covered "auto" shown in the schedule or declarations for
which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on
the lease or loan for that covered "auto," less:
a. The amount paid under the Physical Damage Coverage Section of the
policy; and
b. Any:
(1) overdue lease/loan payments at the time of the "loss";
(2) Financlal penalties Imposed under a lease for excessive use, abnormal wear
and tear or high mileage.
(3) Security deposits not returned by the lessor;
(4) Costs for extended warranties, Credit Life Insurance, Health, Accident or
Disability Insurance purchased with the loan or lease; and
(5) Carry-over balances from previous loans or leases,
The most we will pay under Auto Loan/Lease Gap Coverage for an insured auto Is 25°% of
the actual cash value of that Insured auto at the time of the loss,
XI. GLASS REPAIR— DEDUCTIBLE WAIVER
SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following Is added:
No deductible applies to glass damage if the glass Is repaired rather than replaced,
XII. TWO OR MORE DEDUCTIBLES
SECTION III -PHYSICAL DAMAGE COVERAGE, D, Deductible, the following Is added:
If two or more "company" policies or coverage forms apply to the same accident:
1. If the applicable Business Auto deductible is the smallest, it will be waived; or
2. If the applicable Business Auto deductible is not the smallest, it will he reduced by
the amount of the smallest deductible; or
3. If the loss Involves two or more Business Auto coverage forms or policies the
smallest deductible will be waived.
For the purpose of this endorsement "company" means the company providing this
insurance and any of the affiliated members of the Mercury Insurance Group of companies.
XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS
The requirement In SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The
Event Of Accident, Claim, Suit, Or Loss, a., In the event of "accident", you must notify us of an
"accident" applies only when the "accident" is known to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership;
(3) A member, if you are a limited liability company; or
(4) An executive officer or insurance manager, if you are a corporation,
Copyright 2017 Mercury Insurance Services, LLC, All rights reserved,
MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission tv"
G
Spts P
Risk Management Division
POLICY NUMBER: BA040000014904
X. LOAN/LEASE GAP COVERAGE
SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added:
4. In the event of a "total loss" to a covered "auto" shown in the schedule or declarations for
which Collision and Comprehensive coverage apply, we will pay any unpaid amount due on
the lease or loan for that covered "auto," less:
a, The amount paid under the Physical Damage Coverage Section of the
policy; and
b. Any,
(1) Overdue lease/loan payments at the time of the "lose;
(2) Financial penalties Imposed under a lease for excessive use, abnormal wear
and tear or high mileage,
(3) Security deposits not returned by the lessor;
(4) Costs for extended warranties, Credit Life Insurance, Health, Accident or
Disability Insurance purchased with the loan or lease; and
(5) Carry-over balances from previous loans or leases.
The most we will pay under Auto Loan/Lease Gap Coverage for an insured auto is 25% of
the actual cash value of that insured auto at the time of the loss,
XI, GLASS REPAIR— DEDUCTIBLE WAIVER
SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following Is added:
No deductible applies to glass damage if the glass Is repaired rather than replaced,
XII. TWO OR MORE DEDUCTIBLES
SECTION III -PHYSICAL DAMAGE COVERAGE, D, Deductible, the following is added:
If two or more "company" policies or coverage forms apply to the same accident:
1. If the applicable Business Auto deductible is the smallest, it will be waived; or
2. If the applicable Business Auto deductible is not the smallest, it will be reduced by
the amount of the smallest deductible; or
3. If the loss involves two or more Business Auto coverage forms or policies the
smallest deductible will be waived.
For the purpose of this endorsement "company" means the company providing this
insurance and any of the affiliated members of the Mercury Insurance Group of companies.
XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS
The requirement In SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The
Event Of Accident, Claim, Suit, Or Loss, a., In the event of "accident", you must notify us of an
"accident" applies only when the "accident" is known to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership;
(3) A member, If you are a limited liability company; or
(4) An executive officer or Insurance manager, if you are a corporation.
Copyright 2017 Mercury Insurance Services, LLC, All rights reserved.
MCAS5100817-CA Includes copyrighted material of Insurance Services Off Ice, Inc., with its Permission aSe M1 of p
Risk Management Division
POLICY NUMBER: BA040000014964
HIV, WAIVER OF SUBROGATION
SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 5, Transfer of Rights Of Recovery
Against others To Us, section is replaced by the following:
5. Transfer Of Rights Of Recovery Against Others To Us
We waive any right of recovery we may have against any person or organization to
the extent required of you by a written contract executed prlorto any "accident" or
"loss", providedthat the "accident" or "loss" arises out of the operations
contemplated by such contract. The waiver applies only to the person or
organization designated in such contract.
XV, UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS
SECTION IV- BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment,
Misrepresentation, or Fraud, the following Is added:
Any unintentional omission of or error in information given by you, or unintentional failure
to disclose all exposures or hazards existing as of the effective date or at any time during
the policy period shall not Invalidate or adversely affect the coverage for such exposure or
hazard or prejudice your rights under this Insurance. However, you must report the
undisclosed exposure or hazard to us as soon as reasonably possible after its discovery,
This provision does not affect our right to collect additional premium or exercise our right
of cancellation or non -renewal,
XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE
SECTION IV —BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. For Hired
Auto Physical Damage Coverage, Is replaced by the following:
b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered
"autos" you own:
1. Any covered "auto" you lease, hire, rent or borrow; and
2. Any covered "auto" hired or rented by your "employee" under a contract in
that individual "employee's" name, with your permission, while performing
duties related to the conduct of your business.
However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered
"auto".
XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT
SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, the
following Is added and supersedes any provision to the contrary:
e. This Insurance is primary to and will not seek contribution from any other insurance
available to an additional Insured under your policy provided that;
(1) The additional Insured is a Named Insured under such other insurance; and
(2) You have agreed in writing in a contract or agreement that this Insurance
would be primary and would not seek contribution from any other
insurance available to the additional Insured.
Copyright 2017 Mercury Insurance Services, LLC, All rights reserved.
MCAS5100817-CA Includes copyrighted material of Insurance Services Office, Inc, with Its PatmissloNVVI
Page5of6
._. :.._ _.. vv ! ..
Risk Management Division 11
POLICY NUMBER: BAO4OOOOO14964
XVIII. HIRED AUTO -COVERAGE TERRITORY
SECTION IV -BUSINESS AUTO CONDITIONS, B, General Conditions, 7. Policy Period, Coverage
Territory, e. Anywhere in the world if:, is replaced by the following:
e. Anywhere in the world if:
(1) A covered "auto" Is leased, hired, rented or borrowed without a driver for e
period of 30 days or less; and
(2) The "insured's" responsibility to pay damages Is determined In a "suit" on
the merits, in the United States of America, the territories and possessions
of the United States of America, Puerto Rico, or Canada or In a settlement
we agree to.
XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTALANGUISH
SECTION V— DEFINITIONS, C. "Bodily Injury" Is amended by adding the following;
"Bodily Injury" also includes mental anguish but only when the mental anguish arises from
other bodily Injury, sickness, or disease.
Copyright 2017 Mercury Insurance Services, LLG All rights reserved,
MCA85100817-CA Includes copyrighted material of Insurance services Office, Inc, with Its Permission I'age6of
Py
Management faivision