HomeMy WebLinkAboutCAMPOS, YESSICA (2)City of Santa Ana
1� Clerk of the Council COTC Off Ice 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amendments (if any) are no longer in effect.
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 _ ;-s Tt 7 OK iijrN _
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with t'E 1 Qf , ck M
No. 40��9 a was completed on tq 31 I 109.A and final payment has been made.
(List all amendments. Use space below if needed.)
Department: MrA
Phone/Ext.: rnTjek
Signature: Kf L___,_
Date: 16 1 \a 1 2A2 t
Revised: 10-18-16
INSURANCE NOT ON FILE
WORK MAY NOT PROCEED N-2o19-262
CLERK OF COUNCIL
OATEDEC 2 3 2019 RECREATION SERVICES AGREEMENT
O: PRCS ( / )
Silvia Cuevas THIS AGREEMENT is made and entered into on this 6"' day of December, 2019 by and
between Yessica Campos ("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 advanced Folklorico classes for children in its recreation class program.
B. Provider represents that she is able and willing to provide such services to the City,
C. In undertaking the performance of this Agreement, Provider represents that she is
knowledgeable in 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(709/o) 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 January 1, 2020 and end on December 31, 2020AHess
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, a joint venture relationship, or to allow the
City to exercise discretion or control over the manner in which Provider performs the services
which are the subject matter of this Agreement; however, the services to be provided by Provider
shall be provided in a manner consistent with all applicable standards and regulations governing
such services. Provider shall pay all salaries and wages, employer's social security taxes,
unemployment insurance and similar taxes relating to employees and shall be responsible for all
applicable withholding taxes. Provider is not an agent, representative or employee of City and
Provider shall have no authority to act on behalf of the City.
5. INSURANCE
Prior to undertaking performance of work under this Agreement, Provider shall maintain
and shall require its subcontractors, if any, to obtain and maintain insurance as described below:
a. Commercial General Liability Insurance. Provider shall maintain commercial general
liability insurance which shall include, but not be limited to protection against claims arising from
bodily and personal injury, including death resulting therefrom and damage to property, resulting
from any act or occurrence arising out of Provider's operations in the performance of this
Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall
be not less than the following: single limit coverage applying to bodily and personal injury,
including death resulting therefrom, and property damage, in the total amount of $1,000,000 per
occurrence and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers,
employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not
contributory with respect to insurance or self-insurance programs maintained by the City; and (c)
contain standard separation of insured's provisions.
b. Worker's Compensation Insurance. In accordance with California State law, Provider,
if Provider has any employees, is required to be insured against liability for worker's compensation
or to undertake self-insurance. Prior to commencing the performance of the work under this
Agreement, Provider agrees to obtain and maintain any employer's liability insurance with limits
not less than $1,000,000 per accident.
c. The following requirements apply to the insurance to be provided by Provider pursuant
to this section:
i. Consultant shall maintain all insurance required above in full force and effect for
the entire period covered by this Agreement.
ii. Certificates of insurance shall be furnished to the City upon execution of this
Agreement and shall be approved by the City.
iii. Certificates and policies shall state that the policies shall not be canceled or reduced
in coverage or changed in any other material aspect without thirty (30) days prior
written notice to the City.
iv. Where the amounts or coverage provided by the certificates of insurance provides
coverage greater than those listed by this Agreement, the amounts provided by the
certificates of insurance shall be incorporated by reference into the Agreement.
V. Consultant shall supply City with a fully executed additional insured endorsement.
d. If Provider fails or refuses to produce or maintain the insurance required by this section
or fails or refuses to furnish the City with required proof that insurance has been procured and is
in force and paid for, the City shall have the right, at the City's election, to terminate this
Agreement. Such termination shall not affect Provider's right to be paid for its time and materials
expended prior to notification of termination. Provider waives the right to receive compensation
and agrees to indemnify the City for any work performed prior to approval of insurance by the
City.
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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 1 of this
Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution,
judicial or equitable relief is due by reason of the 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 bold 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. LIVE SCAN BACKGROUND CHECK
Provider, and any employees, subcontractors or substitutes, shall arrange for and submit
their fingerprints for a criminal background check through the Department of Justice through the
City's Human Resources Department process. Consultant shall be responsible for all charges
associated with fingerprinting. Consultant shall not perform any services pursuant to this
Agreement until clearance is received and Consultant is notified by the City's Parks, Recreation
and Community Services Department.
9. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this Agreement
shall be in writing and shall be deemed to be properly given if delivered in person or mailed by
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: Yessica Campos
7082 Senway Drive, Apt. 5
Westminster, CA 92683
Phone: (714) 614-3858
Email: yessicacamposI8@yahoo.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.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Provider regarding the subject matter herein, and supersedes any and all other agreements, oral or
written, between the parties. In the event of a conflict between the terms of this Agreement and
any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be
modified except by written instrument signed by the City and by an authorized representative of
Provider. The parties agree that any 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 party, which is not embodied herein.
El
11. ASSIGNMENTISUBSTITUTES
a. Assignment. The experience, knowledge, capability and reputation of Provider were a
substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign,
transfer, delegate, or subcontract any interest herein without the prior written consent of the City
and any such assignment, transfer, delegation or subcontract without the City's prior written
consent shall be considered null and void.
b. Substitutes. In the event Provider is not able to teach a class due to illness or some other
cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified
substitute instructor to teach the class at its regular time and place. Provider shall ensure that
substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance
and live scan requirements contained herein. Evidence of compliance with City's insurance and
live scan requirements shall be provided upon request. Provider must immediately notify the City
of the substitute instructor's name, qualifications, address and phone number. If Provider cannot
procure a qualified substitute and the City is unable to assist in this regard, then the class shall be
canceled and a make-up class must be added to the session. Provider must notify participants as
soon as possible of any class cancellation and make-up class. Provider must personally teach at
least seventy-five percent (75%) of its offered classes.
12. TERMINATION
a. This Agreement may be terminated by the City upon thirty (30) days written notice of
termination. In such event, Provider shall be entitled to receive, and City shall pay Provider,
compensation for all services rendered prior to the effective date of termination.
b. Termination or cancellation of classes by the Provider outside of Section I Lb. 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, gender identity, gender expression, gender, medical conditions, genetic
information, or military and veteran status, 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]
N-2019-262
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and
year first above written.
ATTEST:
`Y 07
\v CX
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By: Ot,f1A
Laura A. Rossini
Senior Assistant City Attorney
RECOMMENDED 77ROVAL:
CITY OF SANTA ANA
Kristine Ridge
City Manager
Lila Ry(iI fff - Yessica
Ex tive Director of Parks,
Recreation and Community Services Agency
Exhibit A
SCOPE OF SERVICES
A. Provider shall conduct Provider shall conduct advanced Folklorico classes for children
aged 5-16 years.
B. Provider shall teach such or similar classes (1) at the times below at a facility to be
designated by the City or (2) on a schedule otherwise 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: Yessica Campos
LOCATION: Memorial Center, 2102 S. Flower St., Santa Ana, (714) 647-4242
llama class
Class will consist of mastering of footwork and utilization of props such as fans, bottles,
cups. Additional dances of various regions of Mexico will be explored. Solo and group
dances will be performed for the City of Santa Ana public events, throughout the year
such as Fiesta Patrias, Fiesta Navidena, etc.
■ Danza Folldorico class will consist of monthly sessions, 2 per week, 1 class per
dap, 1 hour and fifteen (15) minutes per day.
C. Provider shall provide all materials, supplies, equipment, records and personnel.
Provider shall be responsible for clean-up of the facilities and materials and shall ensure
the safety and effectiveness of instruction.
D. Participants must have previous experience and instructor approval is required prior to
enrolling.
E. Additional costs will be incurred for practice skirts, shoes and performance equipment,
and there is a $5.00 additional cost for material fee for events or supplies needed for the
month of special events.
F. Provider shall not transport any class participants to any performances held for public
events or for any other reason.
CLASS SIZE
A. Each class must have a minimum of 5 paid students and no more than a maximum of 23,
B. No registration will be accepted after the second meeting of class.
C. If the minimum registration has not been reached by the second class, the class shall be
canceled. Provider will be under no obligation to provide services for canceled classes,
and the City will have no further obligations to pay Provider compensation for the
remaining classes that were canceled 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,
ACORO® CERTIFICATE OF LIABILITY INSURANCE
DATE(MLVDD/YYYY)
v16 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 policyy((ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the poll cy, 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
Foil Wayne IN 46804
CONTACT NAME: Mass Me'chandlsln
FAX
AcNo, Exl : 1-800-648-6406 (AC,NI ; 1-260-459-5940
EMAIL
ADDRESS: info@danceinsurance-kkGom
PRODUCER
CUSTOMER ID:
INSURERS AFFORDING COVERAGE
NAILE
INSURED 2001203543 CP# 11
Yessica Campos
7082 Fenway Dr. Apt5
Westminster. CA 92683
A Member of the Sports, Leisure & Entertainment RPG
INSURER A: Nationwide Mutual Insurance Company
23787
INSURER B:
INSURER C:
INSURER O:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2000451701 REVISION NUMBER:
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.
a1SR
LTA
TYPE OF INSURANCE
ADDL
INSD
SUER
,VD
POLICY NUMBER
POLICY EFF
AYDDI
POLICY OP
MWDD/Y
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
6BRPGOOD0007214200
01/01/20
OV01/21
EACHOOCURRENCE
$11000,000
CLAIMSMADE ❑X OCCUR
12:01 AM
12:01 AM
DAMAGE TO RENTED
PREMISES Ea Olxuna,re
$1,000.000
MED EXP(Any One Doran)
$5,000
PERSONAL A ADV INJURY
$1,DDO,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$5,D00,G00
POLICY ❑ PROJECT LOC
PRODUCTS-COMP/OP AGG
$1,D00.000
OTHER:
PROFESSIONAL UABILRY
$1,DOO.000
LEGAL UPS TO PARTICIPANTS
$1.000.000
AUTOMOBILE
LIABILITY
coRRI�denl
BODILY INJURY (Per peraI
AUTO
IANY
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY ME, accieam)
HIRED NON-0WNED
PROPERTY DAMAGE
AUTOSONLY AUTOS ONLY
Per accmnt
X
Not provided while in Hawaii
LIAR OCCUR
EACH OCCURRENCE
AGGREGATE
EXCESS DAB CLAIMS -MADE
DEC PETENTION
WORKERS COMPENSATION
ANO EMPLOYERS' UASILITY
N/A
PER STATUTE OTHER
ANY PROPRIETORPARTNER/ YIN
EXECUTIVE OFFICERMEMBER
El- EACH ACCIDENT
El DISEASE -EA EMPLOYEE
EXCLUDED? (MandMory In NH)
It yea, tlettraie UMer
DESCRIPTION OF OPERATIONS below
EL DISEASE —POLICY UNIT
MEDICAL PAYMENTS FOR PARTICIPANTS
PRIMARY MEDICAL
EXCESS MEDICAL
OESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACORD 101, A4dilionel Remarks Schedule, may be attaclmC it more Wien IS MI
Non -Certified Instructor of: Ballet, Folk Dancing
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.
The general liability policy is primary, subject to the policy terms and conditions, as per form CG 00 01.
This certificate voids and replaces certificate # W01650751.
CERTIFICATE HOLDER CANCELLATION
City of Santa Ana
Risk Management Division REVIE
ED & APPROVED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
20 CIVIC Center Plaza
Y RIS
ANAGEMENT DIVISIO
THE POLICY PROVISIONS.
AUTHORQED REPRESENTATIVE
Santa Ana, CA 92702
Owner/Manager/Lessor of Premise
20 2019
A;E*f /a"-�
019W2015 ACORD CORPORATION. All rights reserved.
SAMANTHA M. LAMBERT
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: 6BRPG0000007214200
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
IInsured Person(s) Or
City of Santa Ana, officers, agents, employees, and volunteers
Risk Management Division
20 Civic Center Plaza
Santa Ana, CA 92702
Named Insured: Yessica Campos
CP# 11
Information required to complete this Schedule, if not shown above will be shown in the Declarations.
A. Section II —Who Is An Insured is amended to Include as an
additional insured the person(s) or organization(s) shown in the
Schedule, but only with respect to liability for 'bodily 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.
CG 20 26 0413
B. With respect to the insurance afforded to these additional insureds,
the following is added to Section III — Umits Of Insurance:
If coverage provided to the additional insured is required by a
contract or agreement, the most we will pay on behalf of the
additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in
the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of
Insurance shown in the Declarations.
REV WED &APPROVED
By 5 MANAGEMENT DIVISION
_0EC 2 01019
SAMANTHA M. LAMBERT
0 Insurance Services Office, Inc., 2012
Page 2 of 2
POLICY NUMBER: 6BRPG0000007214200 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
Risk Management Division
20 Civic Center Plaza
Santa Ana, CA 92702
Effective: 01 /01 /2020 — 01 /01 /2021
Named Insured: Yessica Campos
CP# 11
REVIEWED & APPROVED
9Y Ri MANAGEMENT DIVISION
EC
202019
SAMANTHA M. LAMBERT
SRPG8018 09108
POLICY NUMBER: 6BRPG0000007214200
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CANCELLATION
This endorsement modifies insurance under the following:
COMMON POLICY CONDITIONS, A. Cancellation, 2.1b. 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: Yessica Campos
Additional Insured: City of Santa Ana, officers, agents, employees, and volunteers
Risk Management Division
20 Civic Center Plaza
Santa Ana, CA 92702
Effective: 01 /01 /2020 — 01 /01 /2021
CP# 11
REVI WED & APPROVED
By Ri MANAGEMENT DIVISION
202
SRPG8016 SAMANTHA M. LAMBERT 09/0a
POLICY NUMBER: 6BRPG0000007214200
INTERLINE
IL12011185
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number 1
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000007214200
01/01/20
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Yessica Campos
K&K Insurance Group, Inc.
COVERAGE PARTS AFFECTED
Common Policy Conditions
CHANGES
Form Number: SRPG8016
❑X Add Form F-1 Delete Form
El Amend Form as Follows:
CP# 11
Authorized Representative Signature
REVI;By
RiAGEMENT DIVISION
202019
�AMANTHA M. LAMBERT
IL 12 01 11 85 Copyright, nsurance Services Office, Inc., 1983 Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc., 1983
POLICY NUMBER: 6BRPG0000007214200
INTERLINE
IL 12 01 11 85
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number 2
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000007214200
01/01/20
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Yessica Campos
K&K Insurance Group, Inc.
COVERAGE PARTS AFFECTED
COMMERCIAL GENERAL LIABILITY COVERAGE
CHANGES
The following SRPG8018 form is added to the policy.
CP# 11
Authorized Representative Si(,
REV ED & APPROVED
By S MANAGEMENT DIVISION
C 20 2019
IL 1201 11 85 Copyright, AWAR lAcK&WRW983 Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc., 1983
C177OFSANTA ANA
RISH MANAGEMENT d4.a&- 4HUMAN RESOURCES
NLIn. 1giny Rrsk . Positive Ch.mge EE�
WORKERS' COMPENSATION DECLARATION
Yessica Campos
(NomelTitle)
following declaration:
hereby affirm under penalty of perjury, the
I certify on behalf of City of Santa Ana
of my contract for
that during the term
(Consultant/Company Name)
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: November 19,2019
Print Name: Yessica Campos
Print Title: instructor
Signature:
Telephone: 71
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.
REVI ED &APPROVED
y Ris AN!C MEM DIVISION
20 2019
--- --- - — -- - - SAMANiHA M. LAMBERT- - - - -- -----
1:IRisk Mgmthnsurance RequirementslWC Declaration 08152019
Yessica Campos
7082 Fenway Dr. #5
Westminster, CA. 92683
Oct 23, 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, Yessica Campos, Dance Instructor, hereby release the City of Automobile Liability.
I do not useldrive any vehicle during the course and scope of my course/instruction class.
During the term Jan 1, 2020 through Dec 31, 2020, N-2019.005 I will be teaching Danza
Folklorico at Memorial =jpr located at: 2102 S Flower St., Santa Ana.
& APPROVED
,gEMENT DIVISION
202019
M. LAMBERT