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HomeMy WebLinkAboutCHIHIRO SANOCity of Santa Ana COM Office Use Onty ✓ -.. Clerk of the Council 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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). Call 647-1520 if you have any questions. The agreement with No. QN&�W\ Y-0 car i C' N-2020-173 was completed on ►0109 tWjj and final payment has been made. (List all amendments. Use space below N needed.) Department: QQC$(� Phone/Ext.: F:1 q Signature: p Date: \\11420 i9agreementslformsUorm-agreement termination form_goldenroi INSURANCE ON FILE VVORK MAY PROCEED A,iTll. INSUFlnnirF pXPIU l2/v8/2�2� N-2020-173 (u yr Q RECREATION SERVICES AGREEMENT 'P��CO�Si�U THIS AGREEMENT is made and entered into on this 5th day of October, 2020 by and Ll. between Chibiro Sano ("Provider"), an individual 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"). City and Provider are also referred to as "the Parties." RECITALS A. The City desires to retain a recreation service provider having special skills, resources and N knowledge to provide Yoga in the Park classes in its recreation class program. ry CDB. Provider represents that she is able and willing to provide such services to the City. C. hi 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. D. The Parties acknowledge that the City intends to operate a pilot program for conducting certain recreational classes in City parks in an effort to provide recreational activities to the public but balance the need to comply with all COVID-19 guidance and restrictions, including but not limited to social distancing and wearing masks. Provider has requested to participate in this pilot program. 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 A. Provider shall perform those services as set forth in Exhibit A to this Agreement. B. Provider acknowledges that currently the State, County and City are operating under emergency declarations due to COVID-19. Asa result, there are restrictions in place effecting the ability to offer recreation classes and/or have persons attend classes pursuant to orders from the Orange County Health Officer, the California Public Health Officer, and guidance from the Centers for Disease Control ("CDC"), California Department of Public Health ("CDPH"), the Orange County Health Care Agency ("OCHCA") and the City itself. C. All classes operated pursuant to the City's pilot program for conducting outside recreation classes at City Parks will comply with all applicable guidance and public health orders, including those from the CDC, CDPH, OCHCA, and the City for as long as those orders and guidance remain in place. Provider will remind participants of these guidelines. To the extent that Provider needs assistance with enforcing any rules or requirements, Provider will contact a City Parks' employee or City security for assistance. D. All participants in the classes will have their temperature taken and will be expected to maintain six (6) feet distance from other participants at all times, wear a mask, and practice appropriate handwashing and sanitizing. E. Provider shall not attend a class or teach any class if Provider is sick or has any symptom(s) associated with COVID-19 including but not limited to, fever above 100.4, chills, cough, shortness of breath loss of taste or smell, nausea, muscle or body aches, vomiting, headache, sore throat or diarrhea. F. Provider will not attend class or teach a class if Provider or any member of Provider's household has been asked to quarantine or self -isolate due to symptoms of COVID-19 or a positive test result for COVID-19. G. Provider agrees to have Provider's temperature taken prior to every class, maintain appropriate social distance, and where a mask or face shield. H. Provider acknowledges that, to the extent that City is able to and chooses to conduct classes indoors, this Agreement will also cover classes conducted at one of City's recreational centers during the term of 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. 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 October 10, 2020 and end on October 9, 2021 unless terminated earlier in accordance with Section 13 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 ofinsured'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. COVID-19 ASSUMPTION OF RISK AND WAIVER Provider acknowledges that Provider could be exposed to persons that may have COVID- 19 providing services pursuant to this Agreement. Provider understands that interacting with any person currently comes with the inherent risk of exposure to COVID-19 and that COVID-19 is highly contagious. Provider assumes the risks associated with providing services pursuant to this Agreement, namely potential exposure to COVID-19. Provider acknowledges that while some people have no symptoms or mild symptoms from COVID-19, some people have become seriously ill requiring hospitalization and that some people have died from COVID-19. Provider acknowledges that persons over the age of 65 and persons with underlying health conditions are at greater risk of contracting COVID-19 and are potentially risking serious injury or death. Provider is agreeing to provide classes pursuant to this Agreement and does so of Provider's own free will. Provider intends to be legally bound by this assumption of risk, release and waiver and to bind Provider's heirs, personal representatives, next of kin and anyone who may make a claim on Provider's behalf. Provider knowingly releases and waives any and all claims that Provider may have or could have in the future and includes any claims resulting from potential exposure or actual exposure to COVID-1.9, this includes claims for personal injury, transmittal of COVID-19 to others, and/or wrongful death. Provider agrees to hold harmless, defend and indemnify the City, its public officials, officers, employees, volunteers, and agents from any and all claims for liability or damages, including those for exposure to or diagnosis with COVID-19 as a result of providing services pursuant to this Agreement. 8. 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. 9. 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. 10. 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: Chihiro Sano 4365 Johanna Lakewood, CA 90713 Phone: (714) 913-5559 Email: chihirosano(d,email.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. 11. 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. 12. 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. 13. TERMINATION a. This Agreement may be terminated by the City immediately pursuant to any federal, state, county or local health order related to or regarding COVID-19 making it impossible to hold classes. For any other reason, this Agreement may be terminated by.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 1 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. 14. 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. t, 15. 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. 16. 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. 17. 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. 18. 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. 19. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 20. 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-2020-173 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: aisy Gomez Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By:Clrzuno- A R Laura A. Rossini Acting Chief Assistant City Attorney RECOMMENDED FOR APPROVAL: Fr t4igra Rudloff Executive Director of Parks, Recreation and Community Services Agency CITY OF SANTA ANA Kristine Ridge City Manager va@ATJIt t �/ i Chihiro Sano Exhibit A SCOPE OF SERVICES A. Provider shall conduct Yoga in the Park as part of the City's pilot program for ages 16 years and up. B. Provider shall teach such or similar classes (1) at the times below at facilities or in outside park locations to be designated by the City or (2) on a schedule agreed upon, in writing, 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. Yoga in the Park hi this beginning yoga class, we will explore various yoga postures while we enjoy being outside. Yoga poses will stretch and strengthen your body and relax your mind. Escape your daily stress and connect your mind, body and spirit on a yoga mat. INSTRUCTOR: Chihiro Sano LOCATION: El Salvador Park, 1825 W Civic Center Dr., Santa Ana, (714) 647-6558 Introduction to Yoga classes will consist of monthly sessions, held 1 day per week, 50 minutes per day. Ages 16 years and up. 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. CLASS SIZE A. Each class must have a minimum of 2 paid students and no more than 8 students. B. No registration will be accepted after the second meeting of classes. 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 the canceled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were canceled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. Provider will not accept payment for any fees and will direct provider to City's online registration program. 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. PRODUCER Maguire lnsuranm Agency.lnc FWI I Rate PIT 51e IGO Bdla Cynwyd. PA lixi 1401 61061TT900 Chlhiro Sans 4365TOY anna Ave LdewpW,CA90J13- COVERAGES CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATION 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 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 CERIFICATION 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR All INSRU TYPEOFIMURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYYY) MOO dAIRATION DATE(MM/DD/YYYY) UNITS A k GENERAL LIABILITY mEXCIAI GENERAL LIaBIUtt CIAIMSMADE � OCCUR UABUTY AGGREGATE LIMIT APPLIES PER. POUO PROJECT LOC PHPKR03sm9 s 12MB12019 12/09/2020 Da OCWRENCE $I.ow.w GEGI PREM15ESTA oc... ra'e SLOO,OIIO MEDEXPLAny One Parsanl 5L500 �G�RO'JFESSHONAL GEN"L K PERSONAL B AOV INJURY SL.OW.000 GENEMLAGGREGAtE 53.000.000 PRODUCTS-COMP/OPAGG 53,0110.000 AUTOMOBILE UABIUtt ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NONOWNED AUTOS COMBINED SINGLE LIMIT JFAacabentl BODILY INJURY JPar pe rani BODILY INJURY IPeraaWent) PROPERTY DAMAGE Peta sidentl GAMGE LMBlllry ANYAUTO AUTO ONLY - EA ACCIDENT iNLN EA ACC AUTO AUTO ONLY AGO UA /UMBREWLIMIUTY -CUP ❑ MIMSMADE DEDUCTIBLE RETEN TON LOCH OCCURENCE AGGREGATE EMIlOYERS'IMBNTY Y/N. ANY PROPRIETOR/PARTN%EKECUTIVE ❑ OFFICER/MEMBER E%CLUOEO) (Mandatory in NU If Yes. describe antler SPECIAL PROVISIONS W. TORV LIMITSOTH ER E.L. EACH ACCIDENT E.L. DISEASE - EA AMPLOYEE E. DISEASE -POLICY OMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVLSIOM It is understood and agreed that the lollowlrig early Is added as as addaunpi Insured lad Doty w0h respmUsl .,he opera xas of the named assured except that haOdilY resulting from The additional insured s sole negligence Cmlduale of Insurance hill provide Way NO) da, Ene, wn,,a. notice of cancellaonn CERTIFICATE HOLDER CANCELLATION Lrty of Santa Ana Risk Management Drvman 20 Cm¢ Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DEXRIBED POLICIES BE CANCELCN BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CENOFICATE HOWER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UA9U1rf OF ANY KIND UPON THE INSURER. in ME" OR REPRESENTATIVES. AUTHORIZEO REPRESENTATIVE REVIEW D & APPROVED y !RiZskNA1qEA`1ENT DIVISION f 1 492019 ACORD 25 (2009/01) $AMAN A M. LAMBERT O 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK803569-008 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 anization s : City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92701- 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. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits 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; & APPROVED ,gEMENT DIVISION 2019 whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SAMANWA M. LAMBERT CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 PI-GL-005 (07/12) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization (Additional Insured): City of Santa Ana Risk Management Division Effective Date: 12/08/2019 SECTION 11— WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of or relating to your negligence in the performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured. The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III — LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. & APPROVED tr,rMENT DiVIS10N 9 2019 Includes copyrightjAsMaRVAK41ffis Office, Inc., with its permission. POLICY NO: PHPK803569-008 POLICY CHANGE DOCUMENT CHANGE # 5 CHANGE EFFECTIVE: 12/08/2019 Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. FWI NAMED INSURED: Chihiro Sano MAILING ADDRESS 4365 Johanna Ave. Lakewood, CA 90713- POLICY PERIOD: FROM 12/08/2019 TO 12/08/2020 at 12:01 A.M. Standard Time at your mailing address shown above. DESCRIPTION: In consideration of the premium reflected, the policy is amended as indicated below: Insured Requested 30 Day Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation Total Annual Total Prorate Additional/Return Premium $0.00 Additional/Return Premium $0.00 Total Annual Total Prorate Additional/Return AdditionaVRetum Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 & APPROVED \GEMENT DIVISION 2019 n Chihiro Sano 4365 Johanna Ave Long Beach, CA. 90713 October 3, 2019 City of Santa Ana Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Auto Insurance Requirement Release of Liability. Dear City of Santa Ana Risk Management Division: I, Chihiro Sano, Dance & Fitness Instructor, hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term Jan 1, 2020 through Dec 3, 2020, N-20"-0 2-. I will be teaching Dance & Fitness classes at El Salvador Center, 1825 W Civic Center Dr., Santa Ana. Garfield Center 318 E. Chestnut St., Santa Ana and Memorial Center, 2102 S. Flower St. Santa Ana, CA Sincerely, Chihiro Sano Dance & Fitness Instructor & APPROVED 1gEMENT DivisiON 19 2019 M. LAMBERT CITY OF SANTA ANA RISK MANAGEMENT. say..a,. ,y HUMAN RESOURCES Managing Risk iivucKu� Positive Change WORKERS' COMPENSATION DECLARATION r (Name/Title) following declaration: I certify on behalf of Recreadon passes hereby affirm under penalty of perjury, the that during the term (Consu$ony'Compony Name) of my contract for Dance and yoga instruction services with the City of Santa Ana, (Type of servke 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: 10:312019 Print Name: ChihiroSano Print Title: Dance and yoga Instructor Signature: Telephone: --- 71 4_913-5W 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 \CEMENT DIVISION 19 2019 M. I.AMRFRT