Loading...
HomeMy WebLinkAboutHOANG, KHAI�, City of Santa Ana �—l! Clerk of the Council cord office use !'.~ ............ AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Is the agreement(s) a permanent record? Yes _ No Return form to the Clerk of the Council Office M-30 . -- t 1 Call 647-1520 if you have any questions. The agreement with No. /�✓ C% 9 6 7 was completed on A1.13111Q0 and final payment has been made. (List all amendments. Use space below if needed.) Department: YMBIK Phone/Ext.: 51191 Signature: Date: Mot 12o21. Revised: 10-18-16 INSURANCE ON FILE 4yQRK M CINAY PROCEED TIL iw6URANCE EXPIRES CLERK Ur COUNCIL ,,,r,- ncP Z 3 2019 O: PRCS ( '/ ) Silvia Cuevas RECREATION SERVICES AGREEMENT N-2019-264 THIS AGREEMENT is made and entered into on this 61' day of December, 2019 by and between Khai Hoang ("Provider") and the City of Santa Ana, a charter city and municipal corporatfon~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,dance/frtness classes in its recreation class program. B. Provider represents that he is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that he 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 (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed $25;000.0 mmually. 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 Decenibe'r.31,j 2020 unless terminated earlier in accordance with Section 12 below. The term of this Agreement may be extended by a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, 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. I 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. 2 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. G 1►11 _ �tl►!_ZNY�=[11�1 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 hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligenceofthe City. 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: Khai Hoang 1440 Poplar Drive Tustin, CA 92780 Phone: (714) 262-3505 Email: Hoang_Khai@hotmail.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 parry, or anyone acting on behalf of any party, which is not embodied herein. 11. ASSIGNMENT/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination, b. Termination or cancellation of classes by the Provider outside of Section I 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 Iaws 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. 0 N-2019-264 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: ln�',� Z — / Daisy Gomez CIerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: w,T&, _ CZ Laura A. Rossini Senior Assistant City Attorney CITY OF SANTA ANA �v Kristine Ridge City Manager PROVIDER: Khai Hoang &S;a6ve Director of Parks, Recreation and Agency Exhibit A SCOPE OF SERVICES A. Provider shall conduct Dance for Fitness for individuals, 55 years and up. B. Provider shall conduct Social Ballroom for individuals, 21 years and up. C. 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: Khai "Kevin" Hoang LOCATION: Southwest Senior Center, 2201 W Mc Fadden Ave., Santa Ana. LOCATION: Jerome Center 726 S Center St. Santa Ana SOCIAL BALLROOM & LINE DANCE You will learn basic ballroom dance steps and line dancing that can be used at social events. Dances for each session are selected from Cha-cha, Rumba, Waltz, Salsa, Tango, etc. Dancing is a great stress reliever and a fun way to exercise that will improve your mobility and overall health. No dance experience or partner required, • Dance Ballroom will consist of 1 hour and 55 minutes, 1 day per week, ages 21 years and up. • Dance Ballroom will consist of 1 hour and 55 minutes, 1 day per week, ages 55 years and up. D. Provider will provide and be responsible for equipment, records, and personnel and cleanup of the facilities and materials necessary to ensure the safety and effectiveness of said instruction. CLASS SIZE 1. Each class must have a minimum of 5 paid students and no more than a maximum of 20. 2. No registration will be accepted after the second meeting of class. 3. In the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Provider will be under no obligation to provide services and the City will have no obligations to pay Consultant compensation CLASS FEES 1. Each participant shall pay class registration fee as established by City. 2. Provider may not waive class participation/registration fees. 3. Only registered participants may participate in class. 4. Any refunds to participants will be made in accordance with City policy. 5. Any material fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MAVOOYYYY) 11/21/2019 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 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 po-Ilcy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemenl(s). PRODUCER K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 CONTACT NAME: Mass Merchandising_„_,,, _ 1-800.648-6406 .1-260-459.6940 Eel : AC No EAMAIL ADDRESS: Info@danceinsurance-kk.com PRODUCER CUSTOMER ID: INSURE S AFFORDING COVERAGE NAICa INSURED 2001196285 CP# 1564 Khai HOang 14401 Poplar Or Tustin, CA 92780 A Member of the Sports, Leisure 5 Entertainment RPG INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 20DO449239 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. Was LTR TYPE OF INSURANCE ADDL TSO �R AVID POLICY NUMBER POLICY EFF POLICY EXP MM1VDMTY LWR9 A X COMMERCIAL GENERAL QABILITY CUUMSMPOE X OCCUR X 6BRP00000006933600 01/01/20 12:01 AM 12:01 AM" EACH OCCURRENCE $1,000.000 DAMAGE TO RENTED PREMISES E. Ocaurmxv $1,000,000 MED EXP A,y are Pr l $5.000 PERSONAL B ADV IWUBY $1,000,000 GI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY ❑PROJECT ❑LOC PRODUCTS-COMP/OP AGO $1,OW,000 PROFESSIONAL LIABILITY $1,000,D00 OTHER: LEGAL LIAR TO PARTICIPANTS $1,000.000 AUTOMOBILE LIABILITY CKWEIY 1 ANY AUTO BODILYINJURY(Per Pe ) OWNED SCHEDULED AUTOS ONLY AUTOS BODILYINJURYIFeraaitlenll HIRED NON -OWNED F PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per atxk X Not provided while in Hawaii LIAR OCCUR EACHOCCURRENCE AGGREGATE EXCESS UAS CLAIM -MADE DEO RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A PER STATUTE OTHER ANY FROPRIETORPARTNER YIN EXECUTIVE OFFICEWMEMBER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE EXCLUDED' M..&wry In NH) II deecriea UAear DEESCSCRIPTION OF OPERAnONS Oelpw E.L. DISEASE - POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACOR0101, Addift.1 Remart$ SCN Ule, my Oe enached it more $pace le r Ulmd) Non -certified Instructor of: Ballroom, Square City of Santa Ana, its officers, agents, employees, and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. This certificate voids and replaces certificate # W01630142, CERTIFICATE HOLDER CANCELLATION City of Santa Ana Risk Management 20 Civic Center Plaza & APPROVED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE REVIEWED Santa Ana, CA 92701 �sRlSk ANAGEMENT DIVISION EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Owner/Manager/Lessor of Prem AUTHORIZED REPRESENTATIVE 27 201911 / 01988-2015 ACORD CORPORATION. All rights reserved. � r i 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: 6BRPG0000006933600 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Or anizatfon s City of Santa Ana, its officers, agents, employees, and volunteers Risk Management 20 Civic Center Plaza Santa Ana, CA 92701 Named Insured: Khai Hoang CP# 1564 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 (a) 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. S. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: It coverage provided to the additional insured is required by a contractor 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. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER: 6BRPG0000006933600 INTERLINE IL 12 01 1185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, POLICY CHANGES Policy Change Number 1 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY SBRPG0000006933600 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Khai Hoang K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED Common Policy Conditions CHANGES Form Number: SRPG8016 Add Form Delete Form 71 Amend Form as Follows: CP# 1564 Authorized Representative Signature AI IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006933600 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 2.b. is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: Khai Hoang Additional Insured: City of Santa Ana, its officers, agents, employees, and volunteers Risk Management 20 Civic Center Plaza Santa Ana, CA 92701 Effective: 01 /01 /20 — 01 /01/20 CP# 1564 1121-(� SRPG8016 09/08 POLICY NUMBER: 6BRPG0000006933600 INTERLINE IL 12 01 1185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 2 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000006933600 01/01/20 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Khai Hoang K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES The following SRPG8018 form is added to the policy. CP# 1564 Authorized Representative Signature IL 12 0111 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRPG0000006933600 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies insurance under the fallowing: 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, its officers, agents, employees, and volunteers Risk Management 20 Civic Center Plaza Santa Ana, CA 92701 Eff ective: 01101 /20 — 01 /01 /20 Named Insured: Khai Hoang CP# 1564 SRPG8018 09/08 Khai Hoan g 14401 Poplar Dr. Tustin, CA. 9278 0 Nov 7, 2w 9 City oS swft %,a Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Auto insurance Requirement Release of Liability. Dear City of Santa Ana Risk Management Division: 1, Khai Hoang, Dance/Fitness Instructor, hereby release the City of Automobile Liability, I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term Jan 1, 2020 through Dec 31, 2020, I will be instructing Dance/Fitness at Southwest Senior, 2201 W McFadden Ave., Jerome center, 726 S Center St., Santa Ana, CA Sin cerly, Khai H�oang Dance/Fitness instructor & APPROVED tGEMENT DIVISION 27 2019 M. LAMBERT CITYOFSANTAANA RISK MANAGEMENT,a 4HUMAN RESOURCES h9�ela.7r�fne�Itlsku�.c�il'tasJt�vetJasuat�e � =4 WORKERS' COMPENSATION IDECLARATION I' X" `Al OOANG hereby affirm under penalty of perjury, the (Name/Ttle) foiiowing deciaration: I certify on behalf of KH,+l /foot 1G } )) tom} that during the term (ConsultantlCompany Name) of my contract for Repreation Classes services with the City of Sanica Ana, (Type of service provided) I will not employ any person in any manner so as to become subject to the workers' compensation ia%as 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 comp4Y with the provisions and provide proof of workers' compensation, coverage immediately. Date: //// /1e2©19 Print Name: Print Title: _ 4,,VCE .ZnIs��Ga�TD�2 Telephone:-� 2- �z-3s_ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND Sr'A&Si,t�JTCT�SG'Eibhslu^i'ECiGu'K)IIAM")11A E3r�iG'u^�iV'i rtSG�S�r"iu^u1GLrti'i11ftDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMP-%GES AS PROVIDER FOR, W SE_C-MON..3706OF T-H.E U480P C00F_, [NTF_RF_ST, AI\lD AT.TOR.NEY'S FEE,-;, & APPROVED QEMEW DIVISION �7 2019 M. LAMBERT k1RIsk M9mtllnsuronce Requirements) WC Declaration 08IS2019