HomeMy WebLinkAboutSUBANDHI, TEREMBANG (2)City of Santa Ana
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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amendments (if any) are no longer in effect.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 'G`-
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions. i p^
The agreement with ��e r� vY1 Y 1�A/1C� � �� YJ rut(Ak •(
No. 0 - -,�OV 1 ',26%1^ was completed on 3' and final payment has been made.
(List all amendments. Use space below if needed.)
Department: Y p-(�
Phone/Ext.: t;
Signature:
Date: a
Revised: 10-18-I6
INSURANCE NOT ON FILE
WORK MAY NOT PROCEED
LERK OF COUNCIL
DATE: Ur.G 2 3 2019
0:PRCS(/)
Silvia Cuevas
RECREATION SERVICES AGREEMENT
N-2019-266
TIES AGREEMENT is made and entered into on this 6'h day of December, 2019 by and
between Terembang Subandhi ("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 Badminton 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.(7,09/o) of all gross revenue received from program participants. Total
revenue to Provider shall not exceed425,000.00 annually. Payment to Provider shall be made
monthly within thirty (30) days followingcompletion 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, 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 j oint 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. Corawereaal-6vneral•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.
6. INDEMNIFICATION
Provider agrees to and shall indemnify, defend and hold harmless the City, its officers,
agents, employees, consultants, special counsel, and representatives from liability: (1) for personal
injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for
personal injury, including death, and claims for property damage, which may arise from the
negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other
persons acting on their behalf which relates to the services described in section 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 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: Mr. Terembang Subandhi
14862 Colleta Place
Westminster, CA 92869
Phone:(714) 677-7437
Email: hut-neent@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. I£ 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
El
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.
11. ASSIGNMENDSUBSTITUTES
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 l.b. must be
given to the City at least thirty (30) days prior to termination/cancellation. Failure to provide
adequate cancellation notice to the City may put future contracting of business with the City at risk
and will result in the City's retention of ten (10%) percent of the final payment to Provider.
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. SEVERABIZITY
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 of 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.
N-2019-266
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and
year first above written.
ATTEST:
-)Clerk of the Council
} t�
APPROVED AS T• F•Cu
SONIA R. CARVALHO
City Attorney
By: JQy., A • gq)�rVL
Laura A. Rossini
Senior Assistant City Attorney
RECOMMENDED
i
CITY OF SANTA ANA
Kristine Ridge
City Manager
AL: PROVIDER:
Terembang Subandhi
Exiedtive Director of Parks,
Recreation and Community Services Agency
EXHIBIT A
SCOPE OF SERVICES
A. Provider shall conduct Badminton for ages 5 years and up.
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: Terry Subandhi
LOCATION: Salgado Community center, 706 N Newhope St. Santa Ana, (714) 571-
4267
Badminton for beginners and free paly for intermediate or advanced players are
provided in a friendly & clean environment.
Badminton will focus on basic fundamentals, rules of the game, court etiquette, proper
warm-up / stretch procedures, cardio-vascular fitness & footwork exercise, basic strokes
— serve, clear/lob, drop, smash, forehand & backhand and demonstration of basic shots,
and singles/doubles/mixed-double drills & strategy — offensive & defensive shots, serve
& service returns and doubles rotation
• Badminton will consist of monthly session, held 1 day per week, 2 hours per day,
ages 5 years and up. $10 per month
• Badminton will consist of monthly session, held 1 day per week, 2 hour per day,
ages 18 years and up. $15 per month
C. Provider will provide and be responsible for equipment, records and personnel. Provider
shall be responsible for clean-up of the facilities and materials and shall ensure the safety
and effectiveness of instruction.
CLASS SIZE
A. Each class must have a minimum of 5 paid students and no more than a maximum of 40.
B. No registration will be accepted after the second meeting of class.
C. 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 Provider Compensation.
CLASS FEES
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.
Page I oft Certificate of Insurance
Special Events
Name Insured:
Terembang Subandhi
14862 Colletta Place
Westminster. CA 92683
Named Additional Insured:
SANTA ANA CITY OF -INDEPENDENT CITIES
RISK MANAGEMENT (SPECIAL EVENT)
20 Civic Center Plaza M-28
SANTA ANA, CA 9270I
Certificate Term 1/12/2020 toll/l/2020 Certificate # COSA19-0017
Coverage CITY OF SANTA ANA Special Event Policy Company: U.S. Specialty Insurance Company
Commercial General Liability Per Master Policy# 19/7004011
Master Policy Effective Date:l I/l/2019 to expiration
Limits $2,000,000 General Aggregate / $1,000,000 Each Occurrence / $1,000,000 Products & Completed operations /
$1,000,000 Personal & Advertising Injury/$300,000 Damage to Rented Premises/ Medical Payments Excluded
Deductibles
$50.00 Premium (Fully Earned)
$0.00 Taxes (Fully Earned)
$40.00 Certificate Fee (Fully Earned)
TRIA
$90.00 Total Amount
Terms &
Conditions 1. Premium and All fees are fully earned. No Cancellations Allowed.
2. Hazard Class: 1
3. Event Location: Albert Salgado Community Center
4. Event Description: Badminton Classes
5. Total Attendance: 120 Vendors: None
6. Attachments: Limited Contractual Endt., Designated Premises, Classification Limitation Endt.
7. Event Date: 1/12/2020 to 11/I/2020; Coverage Dates Twice a Week until I I/I/2020 (84 days total)
8. NO LIQUOR LIABILITY COVERAGE PROVIDED.
9. NO COVERAGE FOR BODILY INJURY TO ATHLETIC PARTICIPANTS AS A RESULT OF THEIR
PARTICIPATION.
Department Parks & Recreation
Exclusions Assault & Battery; Total Pollution; Asbestos; Lead Contamination; Animals; Nuclear, Employment Related
Practices; Liquor Liability; Cross Suits; Independent Contractors; Communicable Disease; Subsidence; Non-
Owned/Hired Auto; New Entities; Unscheduled activities or Events; Athletic Participants; Fireworks and Explosives;
Punitive Damages; Professional Liability; Voluntary Labor (For a complete list of the forms, conditions and
exclusions of the policy, refer to Master Policy.)
The insurance afforded under the specified policy above is subject to all terns, conditions, and exclusions of such
policy. (A copy of the policy is available upon written request.) This coverage applies only to the contractor or event
noted above and does not extend to any other activities or work performed by the holder.
MERRIWETHER & WILLIAMS INSURANCE SERVICES, Inc. should be notified at once of any claim arising
from your operation. Call 1-800420-0555 and a claims representative will assist you in the reporting process.
Coverage is primary and not contributing with any insurance maintained by the above public entitiy. The limits of
insurance apply to each event. If more than one named insured for any one event it will not increase the total limits
of liability available for that event.
BY RI WMp & APPROVED N
N 1 4 ZOZ� Ingrid Merriwether, Presi ent / Merriwether & Williams Insurance Services, Inc.
...... ul'rLAA U I AMBERT
550 Montgomery St., Suite 550 San Francisco, CA 94111 800.420.0555 415.986.3999 fax 415.986.4421 License# 0001378
www.imwis.com
ENDORSEMENT #1
THIS ENDORSEMENT EFFECTIVE: 12:01 A.M., December 9, 2019
FORMS A PART OF POLICY NO.: 19/7004011
ISSUED TO: Tenant Users of Independent Cities Risk Management Authority
BY: U.S. Specialty Insurance Company
The following form is hereby added as attached:
Additional Insured - Primary Insurance - SE 1002 02 10
In consideration of the above there is no additional premium.
All other terms and condition remain the same.
AUTHORIZED SIGNATURE
& APPROVED
incMFNT DIVISION
142020
M. IAMBERT
ENDORSEMENT
This endorsement, effective 12.01 A.M., December 9, 2019
Forms a part of Policy No. 19l7004011
Issued to: Tenant Users of Independent Cities Risk Management Authority
By U.S. Specialty Insurance Company
ADDITIONAL INSURED - PRIMARY INSURANCE
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Subparagraph a. of Paragraph 4. Other Insurance (SECTION IV— COMMERCIAL GENERAL LIABILITY
CONDITIONS) is amended to include the following:
However, coverage under this policy provided to an additional insured will apply as primary insurance where required
by contract, and any other insurance available to such additional insured shall apply as excess and noncontributory
insurance.
All other terms, conditions and exclusions of the policy remain unchanged.
1.
Authorized Representative
& APPROVED
%r,FMENf DIVISION
142020
M. LAMBERT
SE 1002 02 10 Page 1 of 1
Includes copyrighted information of the Insurance Services Offices, Inc., with its permission.
All rights reserved
Terembang (Terry) Subandhi
14862 Colletta Place
Westminster. CA. 92683
Nov 13, 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:
1, Terembang Subandhi, Sports Instructor, hereby release the City of Automobile Liability.
1 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, X2U= 1 will be teaching Badminton at
Salgado Community Center, 706 N Newhope St., Santa Ana, CA.
Sincerely,
Terembanj
Sports Instructor
u/13 /toll
i
R WED
& APPRDOVEoD
AN 14 2020
SAMANTHA M. LAMBERT
I,
CITYOF SANTA ANA
RISK MANAGEMENT a d&,wr 4 HUMAN RESOURCES
Managing Risk avough Positive Change
WORKERS' COMPENSATION DECLARATION
Terembang Subandhi
(Nome/Title)
following declaration:
I certify on behalf of
of my contract for
hereby affirm under penalty of perjury, the
Terembang Subandhi
that during the term
(Consultont/Compony Nome)
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: 11 /13/2019
Print Name: Terembang (Terry) Subandhi
Print Title: Badminton Instructor
Signature: 7;i .
Telephone: (714 6 7 77 7'337
44'-`
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.
& APPROVED
%ncMFNT DivisiON
142020
M. LAMBERT
I:�Risk Mgmt1lnsurance Requirements�WC Declaration 09152019
Jamie Subandhi on behalf of Terembang
14862 Colletta Pace
Westminster, CA. 92863
Dec 16, 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, Jamie Subandhi on behalf of Terembang, badminton, 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 Nov 1, 2020. I will be teaching Badminton at Salgado
community center located at: 706 N Newhope St. Santa Ana
Sincerely,
Jamie Subandhi
On behalf of Terembang Subandhi
& APPROVED
1r:FMENT DIVISION
142920
M. LAMBERT
CITY OF SA NTA ANA
R15K MANAGEMENT. d4.,u s 4 HUMAN RESOURCES rr -:
Managing Risk evougft PosWve Change r
c.
WORKERS' COMPENSATION DECLARATION
Jamie Subandhi on behalf ofTerembangSubandhi hereby affirm under penalty of perjury, the
(Nome/Title)
following declaration:
I certify on behalf of Jamie Subandhi/Terembang Subandhi that during the term
of my contract for
(Consultont/Compony 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: 11 /13/2019
Print Name: Jamie Subandhi
Print Title: Badminton Instructor
Signature:
Telephone: 14)230-5105
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.
& APPROVED
�GFMENT DIVISION
142020
M. LAMBERT
l: Risk Mgmt1ilnsurance Requirements�WC Declaration 08152019