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HomeMy WebLinkAboutRELAMPAGO DEL CIELO, INC.INSURANCE ON FILE WORK MAY PROCEED iIL INSURANCE EXPIRES N-2019-244 al)o AMU 2019 CLERK OF COUNCIL DATE: ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT BETWEEN C)..UO�On) THE CITY OF SANTA ANA AND RELAMPAGO DEL CIELO, INC. C, t no This Artist Grant Agreement ("Agreement") is made and entered this 2011 day of August, 2019, by and between 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"), and Relampago-del Cielo, Inc. ("Grantee") for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program. City and Grantee may herein individually be referred to as a "Party' and collectively be referred to as the "Parties" to the Agreement. RECITALS: A. On July 18, 2019, the Arts and Culture Commission reviewed all applicants and recommended that Grantee be awarded an artist grant based on its Application for its artwork ("Project"). A true and correct copy of Grantee's Application is attached hereto as Exhibit A and incorporated herein by reference. B. In undertaking the performance pursuant to this Agreement, Grantee represents that it is skilled and knowledgeable in the arts and culture arena and that the Project created or performed hereunder will be created or performed in compliance with such standards as may reasonably be expected from an artist. 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. Term. This Agreement shall be effective upon signature by both Parties and shall expire one year from the date` first written above, unless terminated earlier in accordance with this Agreement. 2. Funding. 2.1. Subject to Grantee's performance of all required actions under this Agreement, City shall provide funding, in two disbursements, as detailed below, of an amount not to exceed Seven Thousand, Seven Hundred, Seventy Dollars ($7,770.00) ("Grant Amount" or "Grant"). 2.2. Grantee will be paid in two (2) installments. First payment will be one-half of the funding amount provided above or $3,885.00 and will be provided within thirty (30) days of the full execution of the Agreement by the parties along with a complete invoice submitted by Grantee. The second and final payment will include the remaining amount of $3,885.00 and will be issued within thirty (30) days after the Grantee submits to the City all the proper receipts, invoices and final report for the Project. 2.3. Appropriate performance of the Grantee will be determined by City in its sole discretion. City reserves the right to cease funding after the first disbursement detailed above, and to be reimbursed the initial payment, if Grantee's performance is determined to be insufficient or unacceptable in the City's sole discretion. 2.3. City represents that there is no correlation or connection between its selection of institutions or organizations for grant awards and an institution or organization's business relationship or potential business relationship with City. 3. Grant Activities. Grantee agrees: #2664v2 3.1. To perform the activities described in the Grant Application and Timeline submitted to City for consideration dated May 31, 2019, a copy of which is attached as Exhibit A and incorporated into this Agreement as if set out in full. 3.2. To submit all reports (each, a "Report"), which shall include, at a minimum, the items set forth as required by the Application. No personally identifiable information shall be included in any of the Reports, except where specifically requested. The Reports shall be in a format that is reasonably acceptable to City. City may request additional information as City, in its sole discretion, determines is necessary to monitor performance of this Agreement. City shall have the right to use any Reports submitted by Grantee, or any portion thereof, for any reason. 3.3. Grantee shall maintain all pertinent financial and accounting records pertaining to this Agreement in accordance with generally accepted accounting principles and other procedures reasonably specified by City. Upon termination or expiration of this Agreement or request by City, Grantee shall provide, at its expense, copies of all financial and accounting records produced by it arising out of this Agreement. 3.4. Grantee shall allow audits, compliance or special reviews and inspections, including on -site inspection, with or without prior notice, of Grantee's facilities by City or by third parties designated by City, or their authorized representatives. Grantee shall provide its full cooperation for any such audit, review or inspection, including providing timely access, for examination and copying of records (including computerized records) pertinent books, documents, papers, computer programs and records and reasonable access to its personnel. 3.5. Grantee shall ensure that any areas utilized for the Project are maintained and restored to a well -maintained, safe, sanitary, and clean condition, and kept free of any hazardous waste at all times. All equipment associated with the installation of the artwork, trash and debris shall be removed and cleaned up on a daily basis. Grantee shall place a drop cloth or similar barrier on the ground below the artwork while installation is underway, which barrier shall be removed each day upon completion of an installation session. 3.6. The Project may not contain advertising, religious art, sexual content, negative or violent imagery, convey political partisanship or include any hidden, subliminal or camouflaged messages or statements of any kind or nature. Appropriateness of the content of the Project will be determined by City in its sole discretion. 3.7. The Project may not include any breach of intellectual property, trademarks, brands, or images of illegal activity, and the Grantee must be the copyright holder for the Project. 4. Termination. 4.1. City may immediately terminate this Agreement upon one or more of the following: 4.1.1. Grantee's violation of any federal, state or local law or regulation. 4.1.2. Grantee's breach of any of the terms or conditions of this Agreement, including the Application and Timeline, or any unapproved deviation from said documents that has not been cured within 30 days of written notice of such breach. 4.2. In the event the Agreement is terminated under Section 4.1, City reserves the right to require Grantee to refund any or all grant funds awarded to Grantee under this Agreement, and Grantee agrees to refund to City any or all grant funds awarded under this Agreement. #2664v2 5. Limitation of Liabilit 5.1. IN NO EVENT SHALL CITY BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES OR EXPENSES FOR ANY NEGLIGENCE, BREACH OF CONTRACT OR ANY OTHER ACT ARISING OUT OF OR RELATING TO THIS AGREEMENT OR THE ACTIVITIES COVERED HEREUNDER. 5.2. Section 5 and Section 6 do not limit Grantee's rights, including its ability to seek recovery, against anyone other than City, its directors, officers, employees, agents, successors and assigns. 6. Indemnification 6.1. Grantee-shallr defend; indemnify, protect and hold harmless the City, and its elected and appointed officers, employees, members or agents from and against all claims for damages, liability, cost and expense (including without limitation attorney's fees) arising out of or alleged by third parties to be the result of the negligent acts, errors or omissions or the willful misconduct of the Grantee, and Grantee's employees, subcontractors or other persons, agencies or firms for whom Grantee is legally responsible in connection with the execution of the work covered by this Agreement. Grantee shall have no duty to indemnify or hold harmless the City if claims, damages, liability, costs, expenses (including without limitation, attorney's fees) arise from the sole negligence or sole willful misconduct of the City subsequent to declaration by the Grantee. Grantee's obligations shall survive the termination of this Agreement. 6.2. Grantee agrees to hereby fully release and forever discharge the City from any and all claims, demands, damages, losses, and liabilities (hereinafter collectively referred to as "claims'), which are or may be related to or in any way connected with the negligence or willful misconduct of its officers, officials, employees, or agents in connection with the creation, painting, performance or installation of the Project hereunder. 6.3. Grantee further agrees that City may in good faith and on reasonable terms settle any such claims and that City's right to indemnification shall extend to any such settlement, provided City has given notice of such claim and its intent to settle. City's right to indemnification is in addition to, and may be exercised independently of, any remedy held by City under this Agreement, at law or in equity. The indemnity provision set forth in this Agreement shall survive the termination or expiration of this Agreement indefinitely. 7. Insurance 7.1 Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: CommercialGeneral,Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant'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 #2664v2 damage, in the total amount of $1,000,000 per occurrence, with $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, 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 insureds provisions. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non -owned automobiles. G. Workers..-Compensatio.n. Insurance. In accordance with the provisions of Section 3700 of the Labor Code, Consultant, if Consultant 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, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: i. Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. iii. Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. iv. Where the amounts or coverage provided by the certificates of insurance provides coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Consultant shall supply City with a fully executed additional insured endorsement. e. If Consultant 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 Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 8. General Provisions. 8.1. Grantee shall acquire prior written permission from City for any use of the City name or logo in association with its Project. 8.2. If any parts of this Agreement are held to be invalid or unenforceable, the remaining parts of the Agreement shall continue to be valid and enforceable. #2664v2 8.3. Grantee shall comply with all governmental requirements that may now or in the future become applicable to its activities under this Agreement. 8.4. This Agreement, including Exhibit A, Application, and any amendments or schedules hereto, contain the full understanding and agreement of the Parties with respect to its subject matter, and no waiver, alteration or modification of any of the provisions to this Agreement shall be binding unless in writing and signed by an authorized officer of both Parties. 8.5. No waiver by either Party or any breach, default, or series of breaches or defaults, and no failure, refusal, or neglect of either Party to exercise any right, power, or option given to it under this Agreement or to insist upon strict compliance with the terms of this Agreement shall constitute a waiver of these provisions with respect to any subsequent breach or waiver by either Party or its right at any time thereafter to require exact and strict compliance with provisions of this Agreement. 8.6. Any notice or other communication required or permitted to be made or given by either Party pursuant to this Agreement will be in writing and will be deemed to have been duly given: (i) five (5) business days after the date of mailing if sent by registered or certified U.S. mail, postage prepaid, with return receipt requested; (ii) when transmitted if sent by facsimile, provided a confirmation of transmission is produced by the sending machine; or (iii) when delivered if delivered personally or sent by express courier service. All notices to City shall include a reference to the Project title. All notices will be sent to the other Party at its address as set forth below or at such other address as such Party will have specified in a notice given in accordance with this section: Grantee: 27417117Pn R 0 City: City of Santa Ana Clerk of the Council (M-30) 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702 FAX (714) 647-6956 8.7. This Agreement is subject to all applicable local, State and Federal laws. 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. 8.8. Grantee agrees to comply with all applicable equal opportunity and affirmative action laws as appropriate, Grantee 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, training, utilization, promotion, termination or other #2664v2 employment related activities. Grantee affirms that it is an equal opportunity employer (if applicable) and shall comply with all applicable federal, state and local laws and regulations. 8.9. Any funds provided under this Agreement that are not expended, obligated or otherwise committed by the termination or expiration of this Agreement shall be immediately returned to City. 8.10. Grantee grants to City a non-exclusive, irrevocable, transferable, royalty free, worldwide license to use, reproduce, display, distribute, and prepare derivative works, in any form or media at the discretion of the City for the Project conceived, performed or created as a result of this Agreement. 8.11. Grantee and any of the Grantee's agents, employees or representatives are, for all purposes under this Agreement, an independent contractor and shall not be deemed to be an employee of the City, and none of them shall be entitled to any benefits to which City employees are entitled including but not limited to, overtime, retirement benefits, work's compensation benefits, injury leave or other leave benefits. 8.12. Neither Party shall assign any rights or obligations under this Agreement. 8.13. Each Party 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. 8.14. Each Party warrants that they have executed this Agreement knowingly, freely and voluntarily and with full knowledge of its legal consequences. All parties involved warrant and represent that, prior to executing this Agreement, each Party has had the opportunity to review and consider this matter with legal counsel, and that the terms of this Agreement, and its consequences, are fully understood by each Party. 8.15. This Agreement represents the entire agreement and understanding between the parties, and supersedes any and all prior agreements and understandings between the parties, whether oral or written. 8.16. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. #2664v2 N-2019-244 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA i1 _ � ) DAISY GOM Z '""l KRIS INE RIDGE e4 Clerk of the Council --City Manager APPROVED AS TO FORM: GRANTEE: SONIA R. CARVALHO City Attorney s A c7rd,,, By: (kA . HODGE e::�/� Assist t City Attorney Title:!/Yee d 'rie ,/Li'Z/1//24)7/Z- RECOMMENDED FOR APPROVAL: STEVEN A. MENDOZA Executive Director Community Development Agency #2664v2 EXHIBIT A INVESTING IN THE ARTS GRANT PROGRAM APPLICATION #2664v2 Relampago del Cielo, Inc. Line Item Budget Enter budget categories and projected expenditures for the proposed Droaram: Expenditures Total Expenditures Funded By Total Program Organization Category Funded By Other Sources Budget Budget Santa Ana Grant (Including in - kind) Administrative Staff Salaries and 0 0 83,200 Benefits Contractual/Professional 3,000 0 3,000 0 Services/Stipends Equipment, Material, Supplies 3,000 0 3,000 18,850 Special Events Production 1,200 0 1,200 67,000 Marketing 500 0 500 3,000 TOTAL 7,700 0 7,700 177,700 PROGRAM REVENUE LIST ALL OTHER PROGRAM RESOURCES "Funding Source" total must equal "Total Program Budget" listed above. FUNDING SOURCE AMOUNT Santa Ana Artist Grant $7,700 TOTAL PROGRAM BUDGET $7,700 City of Santa Ana, Community Development Agency 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 (714) 647-5360 A Relampago del Cielo, Inc. Line Item Budget -Revised "Input your information directly onto this form (2 pages) and upload onto Submittable.com. PERSONNEL Description of Personnel (contracted instructors, lecturer honorarium, artist stipend, etc.) Total Compensation Grant Funds Requested Instructor Stipend, Emilio Rivas, instructor/lecturer in Mexi- can Folklorico Dances of Mexico September 2019-June 2020 $3,000 $3,000 EQUIPMENT, MATERIALS, AND SUPPLIES Item (equipment, materials, supplies) Quantity Unit Cost Total Cost Grant Funds Requested Veracruz and Michoacan costumes acces- sories, for 30 participants (estimated) 30 $50 $1,500 $1,500 dance shoes 30 $50 $1,500 $1,500 SPECIAL EVENTS Description Grant Funds (permits, fees, facility rental for project, Total Cost marketing) Requested Studio Facility fee $50 per hour. Sessions 1.5 hours ea. $1,200 $1,200 $75 x 16 Workshop sessions= $1,200 Marketing, printing, flyers, program. postage $500 $500 City of Santa Ana, Community Development Agency 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 (714) 647-5360 Project Timeline "Input your information directly onto this form and upload onto Submittable.com. DATE ACTION OUTCOME Septem- Develop workshop curriculum and orientation Complete timeline and curriculum. Two ber 2019 packet. Seek Santa Ana public community orientation meetings will be given. Confirm events. Obtain necessary permits and performance at Santa Ana community authorizations. Plan orientation meetings. events and senior centers. Month Outreach and enrollment of Santa Ana Raise community awareness about the before community residence in the Folk -Art opportunity to enroll Santa Ana residents in the start- Workshop, "Beyond the Steps"- Tradition and the Mexican Folk -Art Workshop; Educate up of Culture". families in a deeper appreciation and the knowledge of the Mexican culture of their Project. forbears. ; Enroll up to 30 seniors in the workshop. October - Begin workshop sessions; lectures and Participants will learn the dances, "La December demonstrations and dance steps reflecting the Bruja" and "La Rama". Participants will 2019 historical insight of the dances from have the opportunity to perform at Veracruz, community events, senior centers and for their families. February- Begin workshop sessions; lectures and Participants will learn the dances, "Las May 2020 demonstrations and dance steps reflecting the Ihuiris" and "Flor Canela" from the state of historical insight of the dances from Michoacan. Participants will have the Michoacan. opportunity to perform at community events, senior centers and for their families. June 2020 Celebration and Recognition A Graduation Ceremony will be held for the participants and acknowledged with a certificate of appreciation. Families, supporters and dignitaries will be invited. Commercial Certificate of Insurance FARM_ E R s� Agency GA13IRL A. DIAZ Name 2706 HARBOR BLVD, STE & Issue Date (MIvVDD/YY) 08/27/1� COSTA MESA, CA 92626���JJJJ Address 714- 34-7600 This certificate Is issued as a matter of Information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the St 97 Dist, 61 Agent 32T'f coverage afforded by the policies shown below. Companies Providing Coverage: Insured Company A Truck Insurance Exchange REL-AMPAGO DEL CTELO, INC. Name DBA: BALLET FOLKLORICO Company B Farmers Insurance Exchange & 600 W. SANTA ANA BLVII Latta company C Mid -Century Insurance Company Address SANTA ANA, CA 92704 Learr Company Letter Coverages This is to certify that the policies of insurance listed below have been Issued to the Insured named above for the policy period Indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate may be Issued or may pertain, the insurance afforded by the policies described herein Is subject to all the terms, exclusions and conditions of such policies. Limits shown may have been reduced by paid claims. Co' Ltr. Type of Insurance Poll Number Policy Effective Date ehtn4lIM" Policy Expiration Date (MMrDD M poll Limits cY X General Liability 6043345-09 03/07/19 03/07/20,, General Aggregate $4,000,000 X Commercial General Products-Comp/OPS Aggregate $2,000,000 Liability B X - Occurrence Version Personal ng I AdveNsingfn(ury $2,1X10,000 Contractual - Incidental Each Occurrence $2,000,000 Only Fire Damage (Any one f re) S 100,000 Owners & Contractors Prot, Medical Expense i (Any one person) $5,000 Automobile Liability i Combined Single All Owned Commercial Limit S Autos Bodily rn,'tury Scheduled Autos (Per person) S Hired Autos Bodily fnjury $ Nan -Owned Autos REVIEWED & APPROVE (Per accident) Garage. Liability By Risk MAN DEMENT Divisi N Property Damage S Garage Aggregate $ Umbrella Liability Limit $ workers' Compensation FRANCINE 'SiLMRTAF Statutory and Each Accident $ Disease - Each amptoym S Employers' Liability Disease - PolicyLlmit S Description of OperatlonsNehicles/Restrictions/Special items: CERTIFICATE HOLDER BELOW (ALSO LISTED AS ADDITIONAL INSURED ON POLICY) City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contact, agreement or memorandurn of understanding, This insurance coverage shall I be primary, and any insurance carried by the City shaU be excess and noncontributory. Certificate Holder Cancellation City of Santa Ana Should any of the above described policies be cancelled before the expiration date Name Risk Management Division thereof. the Issuing company will endeavor to mail 30 days written notice to the & 20 Civic Center Plaza, 4th Floor certificate holder named to the left, but failure to mail such notice shall Impose no Address Santa Ana, CA 92702 obligation or liability of any kind upon the company its agents or representatives. Gabriel A. Diaz Agency; 97-61-32M a we 66-2492 4.94 Copy Distribution: Service Center Copy and Agent's Copy War Gabriel@ Cramer Arts & Culture Office Community Development Agency 20 Civic Center Plaza Santa Ana, CA 92701 Dear Gabriela, Per your request of insurance documents, Relampago del Cielo, Inc. doess4ta ,own_O,Y`auuttos, and will not be using any owned autos, hired autos, or non -owned autos during the scope and services of the artist grant contract/agreement. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION C V182019 FRANCINE R. VILLAREAL Please let us know if you need any additional information. Thank you, Marlene Pena-Marin Lucy Santa r Ornelas Artistic Director Board President WORKERS COMPEN$AMIOITAfND,JMELOYERS LIABILITY POLICY r� 23-1229-FAC1 POLICY NO. 92- A-J324-6 REPLACES NO. 9-EW-N768-1 STATE FARM FIRE AND CASUALTY COMPANY PO Box 853925, Richardson TX 75085-$925 NAMED INSURED & MAILING ADDRESS: Prepared 4BATRpRELAMPAGOADEL CIELO SOANBTAXANASCA 92703-0158 Thank you for allowing State Farmfto provide your business with Workers' Compensation Insurance, To help you remain com liantwith your state(s) regulations, required posters have been made available to you through www,statefarin.com! It is YOUR RESPONSIBILITY TO POST this information as required by the state(s) in which you conduct business. To download and printyour required postings: 1. Go to www.statefarm.com 2. Select Explore (on the top left) 3. Under Claims, Select'Claims Help' 4. Select Business Insurance Claims (in the left navigation) 5. Select Workers' Compensation 6, Scroll and locate the State(s) you operate in and click on the link The information on the right side of the page includes state required bulletins and posters which need to be printed and dlsabual in your place of business. In addition, while we hope you never experience a workplace injury, we want you to be prepared in the eventyou need to report a claim. You can also download and printthe First Report of Injury documentfrom the same web page. On the right side of the page you will locate the'First Report of Injury; which is YOUR RESPONSIBILITY TO USE TO NOTIFY US OF ALL EMPLOYEE INJURIES as soon as the injury occurs. In addition, the information on the left side of the page is whatyou will need when reporting a claim, including phone and fax numbers and mailing address. If you do not have access to the internet or the ability to printthe required posters, please contact your State Fart agent or call I-B55-264.2229 for a claims kit to be mailed to you. Again, we thank you for choosing State Farm to provide your business with Workers' Compensation Insurance, REVIEWED & APPROVED 05 / 20 / 201 9 a9r c3J 2 to 2i-2ntr Iruaoa�I By RISk MANAGEMENT DMSiON ©Copyright, State Farm Mutual Automobile Insurance Company, 20e8 � � n Includes copyrighted material of Insurance Services office, Inc., with its permission. 2ZILIALAL RANCINE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE 23-1229-FAC1 POLICY NO. 92-GA-0324-6 COVERAGE IS PROVIDED BY REPLACES NO. 92-EW-N768-1 STATE FARM FIRE AND CASUALTY COMPANY PO Box 853925, Richardson TX 75085-3925 NAMED INSTREDANA &LMAILING ADDRESS SANDBA RELAMPAGO DEL CIELO PO BOX 315Q SANTA ANA cA 92703-0158 NCCI CARRIER CODE NO. 14842 FEIN 953083493 R p CATI N: 600 W ANTA ANA BLVD STE 214A SAANTA ANA CA 92701-4558 INSURED IS AN INDIVIDUAL COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE ------------------------------------------------------------------------------- 2. THE POLICY PERIOD IS FROM 07/01/2019 TO, 07/01/2020 12:01 A.M. STANDARD TIME AT THE INSURED'S MAILING ADD RRESS. ------------------------------------------------------------------------------ 3A. WORKERS COMPENSATION INSURANCE: PART STATESNLISSTEDHHEREE: POLICY TO THE B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY DISEASET $1,000,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $1,000,000 POLICY LIMIT C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO ALL STATES EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A. D. THIS YWC040301D THESE ENDORSEMENTS WCOOOOOOC *EFFECTIVE 07/01/19 ------------------------------------------------------------------------------ 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ------------------------------------------------------------------------------ PREMIUM BASIS TO- RATE/$100 ESTIMATED CODE NOS. AND TAL ESTIMATED AN- REMUNERA- ANNUAL CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM --------------------------------------------------------------------------- B810 176,800 .40 707 CLERICAL OFFICE EMPLOYEES - NOC 8868 COLLEGES OR SCHOOLS - PRIVATE - NOT AUTOMOBILE SCHOOLS - PROFESSORS, TEACHERS OR PROFESSIONAL EMPLOYEES COMPANY SURCHARGE FOR INCREASED EMPLOYERS LIABILITY LIMITS TERRORISM 9740 44,200 REVIEWED & By Risk MANAC40 0 T 28 E ANCINE 221,000 77 03 340 115 W-9 MINIMUM PREMIUM $ 500 CALIFORNIA TOTAL ESTIMATED ANNUAL'PREMIUM $' 1,228 ----------------------------------------------------------- ------------------ PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL STATE DEPOSIT PREMIUM RCHARGE $ 1,228 FRAUD 4.00 SEE SURCHARGE OVERFLOW PAGE PREPARED 05/20/2019 WC 00 00 01 04-84 COUNTERSIGNE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY SURCHARGE QVERFLOW PAGE PAGE NUU; 01 23-1229 FAC1 POLICY NO. 92-GA-J324-6 COVERAGE IS PROVIDED BY STATE FARM FIRE NO CASUALTY COMPANY PO Box 853925, Richardson TX 75085-3925 STATE ASSESSMENT $ 18,00 LBR ENFMT COMPL ASMT $ 4.00 OCC SAFETY HLTH FUND $ 5,000 SUNINNUMBBENEFIT ASMT $ 1.00 REVIEWED & APPROVED By RISK MANAGEMENT Divi510N OCT422019� +FAN4 R. VILI AREAL PREPARED 05/20/2019 WC990003(ED 3-11) Important Information on How Your Workers' Compensation Premium Is Determined and the Audit Process When your policy was issued, the premium was based on an estimate of your business operations and your workers' payroll. At the end of the policy period, an audit will be performed to determine your actual payroll and business operations. We will be able to calculate the final premium from this information. The Audit Process A review of your financial records, such as payroll logs, general ledgers and tax returns will be required, A State Farnirepresentative will contact you by mail, telephone or visit with you in person to obtain the information, It is to your benefit to have your accounting records set up by employee and type of work they perform. We will also obtain a complete description of your business operations to confirm the classification codes on your policy are correct, We will assign the payroll to the classification code(s) that represent the type of work performed and apply the appropriate rating factor to determine your final premium. The final audit premium will be compared to the estimated premium and a Premium Adjustment Statement will be sent to you reflecting any change. Please note that a significant change may require that we also adjust your current policy premium, Items That Affect Your Premium • $�Jc Pronrietor/Palrtner/Officer -The remuneration used for each covered sole proprietor/partner/officer may be either a predetermined arnount, or actual remuneration* subject to a minimum/maximLim. *iremuneration means all payroll and other forms of earning Such as bonuses, commissions, sick stays, meals, and lodging. Employees/Temporary Employees/Leased Employees - Actual remuneration paid to each employee. You may be responsible for temporary/leased employees regardless of the temporary or leasing company s insurance arrangements, Use of Subcontractors - A Certificate of Insurance for Workers' Compensation coverage needs To be obtained annually for every subcontractor you hire. If a subcontractor has no employees, a Certificate of Insurance for contractor's liability coverage needs to be obtained. If certificates are not obtained , the subcontractor and their employees may be considered as your employees for premium calculation, This could substantialty increase your final premium, Eushiess Operations - The actual remuneration will be assigned to a classification code in accordance with industry rules as published by the National Council of Compensation Insurance (NCCI) or specific guidelines as published by your state, All audit information provided will be kept confidential. if you have any questions concerning this information, please contact your State Farm agent. The infbrnicaion containers in this document outlines general concepts. Information required n+ay vary by state and could be impacted bkfflVftD & APPROVED By Risk MANACIEMENT DiviSION State Farm Fire and Casualty Company T Bloomington, lL CI o 6/14 (C) SGG,2 59'•I A 12. FRANCINE R. VILLAREAL Dear commercial policyholder, Whether you're operating a business solo from your home or have multiple locations and employees, it's important to protect your business with what we call a "risk management" program, Establishing and maintaining a risk management program: • Shows concern for your employees' health and safety • May help control losses due to illness or injury State Farina has tools and services to help you establish a program just right for your business or to complement what you're already doing, To learn how State Farm may help you protect your business, complete uid return the card below, or visit stat:efarm,coma, and click the insurance tab, then Business. On behalf of your local State Farris agent, we wish you continued success in managing your business risks! State Farm Workers' Compensation policyholders Some federal and state laws place responsibility on employers to provide safe, healthful workplaces, so it's important to: Know your location's governing authority Know which safety and health standards apply to your business Have and adhere to a program that complies with applicable laws A risk management program may help you: Manage insurance and operating costs Protect profits Improve operating efficiency and productivity Maintain product quality Instill employee and customer confidence A Special Message to Our Workers' Compensation Policyholders in California: State Farm's loss control consultation services are available at no additional cost to our policyholders. Workers' Compensation insurance policyholders may register comments about the insurer's loss control consultation services by writing to: State of California Department of Industrial Relations Division of Occupational Safety and Health P,O. Box 420603 San Francisco, CA 94142 If interested in learning about this information and service, please complete the information below and return to the indicated address: State Farm Insurance Companies PO Box 853925 Richardson, TX 75085-3922 Attn: Business Lines Loss Control Unit Name _ Phone Address E-mail City __ Suite— Zip — Policy Number _ _ Agent — vIFy/ED & APPROVED Or you may also call our Loss Control Unit at: 844-892-8286 or email a LzX jjl5k MANAGFME(vT DIVISION ntex,amnund-lassetrl.934o0x?. ,teLrm.com State Gann products and service ol%rings are not intended to be inclusive oCall potential accidem smuxes, nor n0M V IN1J warrant your compliance with rederal, state, or nw,+ F ANCINF R. VI WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 B (Ed, 1-16) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015, it serves to notify you of certain limitations under the Act, and that your Insurance carrier is charging a premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Act of Terrorism, Including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions In your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions: The definitions provided In this endorsement are based on and have the same meaning as the definitions In the Act. If words or phrases not defined In this endorsement are defined In the Act, the definitions In the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002 and any amendments thereto, Including any amendments resulting from the 'Terrorism Risk Insurance Program Reauthorization Act of 2016. "Act of Terrorism" means any act that Is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism, b. The act is violent or dangerous to human life, properly or Infrastructure. c. The act resulted In damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an Individual or Individuals as part of an effort to coerce the civilian population of the United States or to Influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, Including an act of war, in the case of workers compensation) that Is covered by primary or excess property and casualty insurance Issued by an insurer if the loss occurs in the United States or al the premises of United Slates missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the Immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rate share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate Industry Insured Losses exceed: a. $100,000,000, with respect to such Insured Losses occurring in calendar year 2015, the United States Government will pay 85%of our Insured Losses that exceed our Insurer Deductible. b. $120,000,000, with respect to such Insured Losses occurring In calendar year 2016, the United States Government will pay 84%of our Insured Losses that exceed our Insurer Deductible. c. $140,000,000, with respect to such Insured Losses occurring In calendar year 2017, the United States Government will pay 83% of our Insured Losses that exceed our Insurer Deductible. d. $160,000,000, with respect to such Insured Losses occurring in calendar year 2018, the United States Government will pay 82% of our Insured Losses that exceed our Insurer Deductible. a. $180,000,000, with respect to such Insured Losses occurring in calendar year 2019 Bd t�d P Government will pay 81%of our Insured Losses that exceed our Insurer Deduct�Fe� reN HYrRQVILN {{�� ''DD�� I(M Nl4CEMLN7 DIVISION L $200,000,000, with respect to such Insured Losses occurring in calendar year 202�J,'fH UH�ied States Government will pay 80% of our Insured Losses that exceed our Insurer Deductible. � 1 9 R g019 o Copyrlght 2e16 National Council on Compensation Insurance, Inc. All Nights ne lervdd. � I 0tfUs ,Lc...iF.0908a% FRANCINE R, VILLAREAL WC 00 04 22 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed, 1-15) 2. Notwithstanding Item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000, 3. The premium charge for the coverage your policy provides for Insured Losses Is included In the amount shown In Item A of the Information Page or In the Schedule below. State Schedule Rate Premium This endorsement changes the Polley to Which it Is attached and is effective on the date issued unless olhorwlso stated. (The Information below is required only when this endorsement is Issued subsequent to preparation of the policy,) Endorsement Effective Policy No. Insured insurance Company WC0004228 (Ed. 1-15) Endorsement No. Premium $ Countorsigned By 0 Copyright 20t5 National Council on Compan9allon Insurance, Inc. All Rights Rosarvad, REVIEWED & APPROVED By RISK MANAGEMENT DIVISION 0 T 28 2019-- FRANCINE R. VILLAREAL