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HomeMy WebLinkAboutRELAMPAGO DEL CIELO, INC. (3)CV O N IP,<,,• ' 1N FILE N-2019-244-02 `PWORK i,iA,PROCEED Q CLERK OF COUNCIL X DATE: SECOND AMENDMENT TO ARTS AND CULTURE �SCDR��Yum Le GCf�aby Crumer��DiLt3 ARTIST GRANT PROGRAM AGREEMENT THIS SECOND AMENDMENT TO ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT is made and entered into this 10th day of February, 2021, by and between the City of Santa Ana, a charter city and municipal corporation, organized and existing under the Constitution and laws of the State of California ("City"), and Relampago del Cielo, Inc. ("Grantee"). RECITALS A. City and Grantee entered into Arts and Culture Artist Grant Program Agreement number N-2019-244, dated August 20, 2019, for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program ("said Agreement"). B. City and Grantee entered into a First Amendment to said Agreement dated July 6, 2020, for the purpose of extending the Term of said Agreement until June 30, 2021. C. In accordance with the terms and conditions of said Agreement, the parties now desire to amend Section 1 — Term, to extend said Agreement until June 30, 2022. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions of said Agreement, except as herein modified, the parties agree as follows: 1. Section 1, Term, shall be amended to read as follows: "This Agreement shall commence on the date first written above and terminate on June 30, 2022, unless terminated earlier in accordance with this Agreement. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney." 2. Except as hereinabove modified, all terms and conditions of said Agreement shall remain in full force and effect. Page 1 of 2 N-2019-244-02 IN WITNESS WHEREOF, the Parties have executed this Second Amendment to Arts and Culture Artist Grant Program Agreement the date and year first above written. "P, 51 i GNP lerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Qf orney By: Rya . I odge Assi ant City Attorney RECOMMENDED FOR APPROVAL: STEVEN A. MENDOZA Executive Director Community Development Agency CITY OF SANTA ANA K I TINE RIDGLZ City Manager GRANTEE: MARLENE PENA-MARIN Executive Director Relampago del Cielo, Inc. Page 2 of 2 EXHIBIT A INVESTING IN THE ARTS GRANT PROGRAM APPLICATION #2664z IRelampago del Cielo, Inc. Line Item Budget Enter budget categorlas and oroiected exnenditnraq fnr thm nrnnhenel Category Expenditures . Funded By Santa Ana Grant Expenditures Funded By Other Sources (including in- kind) Total Program Budget Total Organization Budget Administrative Staff Salarlesand Benefits 0 0 83,200 Contractual/Professional Services/Stipends 3,000 0 31000 0 Equipment, Material, Supplies 3,000 0 3,000 18,850 Special Events Production 1,200 0 1,200 67,000 Marketing 500 0 500 3,000 TOTAL 7,700 0 7,700 177,700 PROGRAM REVENUE LIST ALL OTHER PROGRAM RESOURCES "Funding Source" total must equal "Total Program Budget" listed above. FUNDINGSOURCE AMOUNT Santa Ana Artist Grant $7,700 TOTAL PROGRAM BUDGET $7,700 City of Santa Ana, Community Development Agency 20 Civic Center Plaza, M-25, Santa Ana, CA 92701(714) 647-5360 Relampago del Clelo, Inc. Line Item Budget -Revised **Input your information directly onto this form (2 pages) and upload onto Submittabie.com. PERSONNEL Description of Personnel (contracted Instructors, lecturer honorarium, artist stipend, etc,) Total Compensation Grant Funds Requested Instructor Stipend, Emilio Rivas, instructor/lecturer In Mexi- can Folklorico Dances of Mexico September 2019-June 2020 $3,000 $3,000 EQUIPMENT, MATERIALS. AND SUPPLIES Item (equipment, materials, supplies) Quantity Unit Cost Total Cost Grant Funds Requested Veracruz and Michoacan costumes acces- series, for 30 participants (estimated) 30 $50 $1,500 $1,500 dance shoes 30 $50 $1,500 $1,500 SPECIAL EVENTS Description (permits, fees, facility rental for project, Total Cost Grant Funds marketing) Requested Studio Facility fee $50 per hour, Sessions 1.5 hours ea, $1,200 $1,200 $75 x 16 Workshop sessions= $1,200 Marketing, printing, flyers, program. postage $500 $500 City of Santa Ana, Community Development Agency 20 Clvlc Center Plaza, M-25, Santa Ana, CA 92701(714) 647-5360 Project Timeline ^•r++• I--. "" ""Y vi.&v % 1 0 iu1111 ailu upluau unZQ AUUMIXTaDle.corn. GATE ACTiON OUTCOME Septem- Develop workshop curriculum and orientation Complete timellne and curriculum. Two bar 2019 packet. Seek Santa Ana public community orientation meetings will be given, Confirm events, Obtain necessary permits and performance at Santa Ana community authorizations. Plan orientation meetings, events and senior centers. Month Outreach and enrollment of Santa Ana Raise community awareness about the before community residence in the Folic -Art opportunity to enroll Santa Ana residents in the start- Workshop, "Beyond the Steps"- Tradition and the Mexican Folk -Art Workshop; Educate up of Culture". families In a deeper appreciation and the knowledge of the Mexican culture of their Project. forbears.; Enroll up to 30 seniors in the workshop. October- Begin workshop sessions; lectures and Participants will learn the danccs, "La December demonstrations and dance steps reflecting the Bruja" and "La llama". Participants will 2019 historical insight of the dances from have the opportunity to perform at Veracruz, community events, senior centers and for their families. February- Begin workshop sessions; lectures and Participants will learn the dances, "Las May 2020 demonstrations and dance steps reflecting the Ihuiris" and "plor Canela" from the state of historical insight of the dances from Michoacan. Participants will have the Michoacan, opportunity to perform at community events, senior centers and for their families. June 2020 Celebration and Recognition A Graduation Ceremony will be held for the participants and acknowledged with a certificate of appreciation. Families, supporters and dignitaries will be Invited. Commercial Certificate of Insurance Agency GABIEL A. DIAZ Name 2706 P[ARBOR BLVD, STE & COSTA MESA, CA 92626 Address 714-434-7600 St.. 97 Dist. 61 Agent 32M Insured , RELAMPAGO DEL CLELO, INC- Name , DBA:BALLETFOL.KLOR[CO & - 600 W. SANTA ANA BLVD Address - SANTA ANA, CA 92704 • "k FARM E RS Issue Dace (NlIv[/DD/YY) 06/23/20 This certificate Is Issued as a matter of information only and confers no rights upon the certifcate holder. This certificate does not amend, extend or alter the coverage afforded by the policies shown below. Companies Providing Coverage: Company A 'Truck insurance Exchange Letter Company B Farmers Insurance Exchange Letter C.a1 opany C Mid -Century Insurance Company Cnmpony Q Lehr c Coverages This is to certify dial rite pollcles of Insurance listed below have been its led to the Insured named above for the policy period Indicated. Notwithstanding In requlrerst term or condition of any contract or other document with respect to which lids certificate maybe Issued or may pertain, the Insurance afforded by the policies described herein is subjeia to all the terms, exclusions and conditions of such policies. Limits shown may have been r,dueed by paid claims. Co' Type of Insurance Potiry Efflxttve Policy Expiration Lu. _ yP Polley Number Uate _ptwraonm Date 641Inon>7 Policy Limns X General Liability 60,133-45-09 03/07/20-- 4.•:�0 /GkiJ711 General Aggregate - $4,000,000 X Commercial General - Products-Comp/OPS Uabllfty Aggregate S 2,000,000 B I X - Occurrence Version Personal & . I Advertising Injury S 2,000,000 Contractual • Incidental Each Occurrence Only Fire Damage $ 2,OOQ000 Owners & Contractors Prot. (Any one Ore) 1 S 100,000 Medical Expense l .---__. (Any on, Eidson) S 5,000 Automobile Liability I combined single— T------'� All Owned Commercial i Limit S Autos i Bodily In lay i Scheduled Autos l (Per personl S f3 1 X L[IredAutos l i 60433-45.09 03(OZ20 03/07/21 IBodl1Y Injury Non,OwnedAutos Per accident) S 2,000,000 60,133-45-09 03/07/20 03/07/21 GarageUabtlity Property Damage $ incl. Garage Aggregate Umbrella Uability _ By Risk tiaGLntEnr bi _isiaN unto s Workers' Compensation u Statute ry and 0 i Each AccidentEmployers' Liability iDiseasceaee,npie5 4612 Dlsease PabcyLimit SDescription of Operations/Vehicles/RestrictioWLLA _--- -- -----! CERTIFICATE HOLDER BELOW (ALSO LISTED AS ADDITIONAL. INSURED ON POLIM City orSmaa Ana, otliccrs, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement or mermrandu a of understanding. This insurmcu coverage shall be printery, and any insurance carried by the City shall be excess and noncontributory. Certificate Holder — Cancellation . City of Santa Ana Should any of the above described policies be cancelled before the expiration date Name . Risk Management Division thereof. the Issuing company will andeavor to man 30 days written notice to the & 1 20 Civic Center Plaza, 4th Floor certificate holder named to the left, but Fillers to mail such notice shall impose no Address , Santa Ana, CA 92702 obligation or liability of any kand upon the company its aeons or ire i reI smaxtives. Gabriel A. Diaz.Aecney; 97 ' 1-32M Authonztdn�rescntat c Copy DisMbutlon: Service Center Copy trod Agent's Copy eras' CERTIFICATE OF LIABILITY INSURANCE 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 cortlficato holder Is an ADDITIONAL INSURED, the pollcyoos) must have ADDITIONAL INSURED provlsigns or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condlllons of the policy, certain policies may require an endorsement. A statamant on this certificate doos not confer rights to the certificate holder In lieu of such andorsarRManI. PRODUCER StateFami AIDED Lopez, Agent 5b a 3750 N1 McFadden Avenue, Suite E Santa Ana, CA 92704 INSURED DBA Relalnpag0 Dal Cielo PO BOX 7158 Santa Ana. CA 92709 COVPRAGPS cPDTICIrn Yc MI Fire and -- - - r,alvry rvulvla CR: IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE iTHIS INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER FOR THE POLICY PERIOD 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 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. u TERMS. ILA TYPE OF WSURANCE AO L VaR .� POLICY EFF P LIcye P - '-"--"—'--"---- - P011t AfBEO MMO 1 RANDOM" LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS.MAD[. D OCCUR PREMISES wr3eoee _ --- PEkSONRLa ADV INJURY S __._-- GENL AGGRFOAT5 LIMP APPLIES PER (('-� PRNERAL C�L� GE AGGREGATE "--""--- S -f W PROCTSCOMPIOP.AGO_15_- — _ _ _ — POLICY I_!JECTO i OTkC:k t S AUTOMOBILE CoMDIREDSFoLS LI t, $ II-- oABILITY I aOD1Ydde1JURVIParpo sent S ,. OWNED SCHEDULED UT05 ONLY AUTOS HIRED NON -OWNED AUTOS ONLY ' " AUTOS ONLY I 90CILY INJURY IPa ocC�dvN 7R FR YnAAIAGE ESE afSW.@IllL___ S -- UMBRELLA LIAR -. OCCUR Y EACHOCCVHRENCE - $ EXCESS LtAB CWMSSMAOE AGGREGATE ON qEO RETEN $ _ ^- I ANDEMWORKEPL YTRIS'NSAITON LIT AND EMPLOYCRS 11A81UT' PLAT YF Oiry ���" YIN TN'I PROPflICItlfl/PArITNER¢.tECVY'VL Excwncc^ NIA 192-GP-W91]-4 07(011202007lDt12023 x orrlGemmrII --.._— LEnCHACCI0E1i $ CoODD --- L"--- NHl IIMantlalory lm NNl 1 Yes Eovcnbo muter i Do5CRIPTION OF OPERA 'OVP arcw I I F L UI Ea EAEA MP O EE! S 1.00D 000 ' -_ EL DISEASE. POLICY 1000000�- I kCv_��_II 1 L RT 1 S uQyFrB��-tyk,}l,E3aJ+,g+,j-yrµ-UyI./Jp.�Y.pW� OESCHIPOgN OF DYERAil0e13ILUCATION51 VEHICLES (ACOH IS ,IVIRPltil CIV1I�J V1�Ail�U a moll 9paeo IS ngm1 1611'I CIYI A, 6a1 (tr151 URl 0,,IVI MANCINE it. VILLAREAL. City of Santa Ana . Risk Management 20 Civic Center Plaza Santa Ana. CA 9270'' ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Completed by an authorized Slate Farm representative. If signature Is required, please contact a State Farm agent, ©1988-2015 ACORD The ACORD name and logo are registered marks of ACORD All rights reserved. ih, ae5 13A1q ❑ en FR:C=C Gabriela Cramer Arts & Culture Office Community Development Agency 20 Civic Center Plaza Santa Ana, CA 92701 Dear Gabriel@, Per your request of insurance documents, Relampago del Cielo, Inc. does not own any autos, and will not be using any owned autos, hired autos, or non -owned autos during the scope and services of the artist grant contract/agreement. REVIEWED & APPROVED BY Risk MANACIEMENr DiviSioN Pt C t&2019 FRANClNE R, VILLAREAL Please let us know if you need any additional information. Thank you, Marlene Pena-Marin Lucy Santar�Ornelas Artistic Director Board President Commercial Certificate of Insurance Agency GA13Lf3L A, DIAZ Naune . 2706 HARBOR BLVD, STE & - COSTA MESA, CA 92626 Address - 7t4-4.34.7600 St.--'97 _•_, Dist, __,__61 ,_,_Agent-_ 321vf Insured R.ELAIVIi A O'DEL cmn.o, fNC. Name DBA:BAILETFOLKLORIC0 & 600 W. SANTA ANA BLVD Address SANTA ANA, CA 92704 FARMERS'i Issue Date (Tv M/DD/YY) 03/27/19 This certificate is Issued as a matter of Information only and con6!rs nu rights upon the rertlficnta holder. This certificate does not amend, extend or ahor the coverage afforded by tha policies shown below. Companies Providing Coverage: C7ompany A Trek Insurance Lxchange Lone. Company B Farmers Insurance Exchange Loner company C )vlld-Century Insurance Company Inner Cnnrpany D LetGr Coverages This Is to certify that the policies of Insurance listed below have been issued to the Insured named above tor the policy period Indicated. Notwlthstanding any requirement, Latin or condition of ally contract or other document with NsImt to which this certificate may be Issued or may pertain, the Insurance afforded by the policies described herein Is subject to all the terns, exclusions and conditlons of such polleles. Limits shown may have been reduced by paid claims. Co. Type of Insurance { Lu _ X GenerallAbiiity X Coumerdal General Liability B X- OmerienceVersion Contractual - Incidental Only Owners & C:ontracLoi's Prot. Automobile Liability All Owned Cornmr-rrld Autos Scheduled Autos Hired Autos Neal Owned Autos Garagn Liability Umbrella Liability Polio Number Policy Effective Y Date (antenna 60433-45-09 03/07/19 REVIEWED'&APPR( By Risk M1N,AGEMFNr Ili Workers' Compensation FRANCINE R. � i anti Employors' Lioblllty Description of OperasIons/Vehicles/Restrictlons/Special Items: Policy Limits General Aggregate S 4 OOU 000 Products-Comp/OpS ' A gegatc S 2,000,000 Personal K... Advertisl tt In jury S 2,0O0,000 Each Occurrence $2 OUO,p00 Fire Dtuuago (Any one fire) S 100,000 imy one person) 5,000 Combined Single Lfmlt $ Bodily In,('u17 (Per person) S Bodily Injury S (Per accident) Properly D;unage ! S Garage rlggrepue I S Limit S — Statutory �� Each Accident S Disease - each IIraplayu S Disease. -Policy Limit S CERTIFICATE? HOLDER BELOW (ALSO LISTED AS ADDITIONAL INSURED ON POLICY) City of Santa Ann, ofticrn:s, agents, employees, and vohmtoors arc named as additionally insured on this policy pursuant to written contract, agreement or mmnorandmm of understanding. This insurance coverage shall be primary, and any insurnnce carried by the City shall be excess and noncontributory. Certificate Floltler Cancellation City of Santa Ana Should any of the above described policies be cancelled before tide cepiratiun date dame Risk Ntanagemont Division thereof, the killing company will endeavor to mail 30 days written entice to the & 20 Civic Center Plaza, 4dt Floor cerllnme holder maned to dre left, but failure to mna such notice shall Impose no Address Santa Ana, CA 92702 obligation or lability of any kind upon the company, its ag-inis or representatives. A. Diaz Agcnoyl 97-61-3' Nd ,a-a4n2 494 root Gabriela Cramer Arts & Culture office Community Development Agency 20 Civic Center Plaza Santa Ana, CA 92701 Dear Gabriela, Per your request of insurance documents, Relampago del Clelo, Inc. e .,n,ot owp..gnu autos, and will not be using any owned autos, hired autos, or non -owned autos during the scope and services of the artist grant contract/agreement. REVIEWED & APPROVED By Risk Mnrv:urnrr ,r Divisiary ;. C ` g zoas FRANCINE R. VILIARE-jM Please let us know if you need any additional information. Thank you, /(nrn�e'(Ias Marlene Pcna-Marin Lucy Santai J Artistic Director Board President WORKERS CDMPEt, %IRTNTA fJ'f CgLOYERS L IA1310TY 1'OWCY ppI� TT yy N(J, 92- A d3 #- s qq rr 23-1?pp29yy•aF'AC1 Rh�L CLS Nt7, 9-EW-�76 -1 STApaxF8��92 RERAl�alr SIIAL-TX �50g5N3925 NAMED INSURED ✓t MAItINca ADDRESS; $ NT�I AAA A A92iO3-0158 Thank you for allowing State Farrho provide your business with Workers' Compensation Insurance, To help you romain,dVjdk•with-yourstoto(s)regulations, required posters have been made available to you through www,statotarm.com® It is M this information as required by the stata(s) In which you conduct business. To download and printyaur required postings; i, as to www,stateform,com 2, Select Explore (an the top left) 3, Under Claims, Solect'ClWms Help' 4, Seloct Business Insuranoa Claims (In the left navigation) 5. Solent Workers' Compensation 6, Scroll and ]costs the State(s) you operate in and click on the link 'The Information on the right side of the page includes state required bulletins and posters which need to be pb.ptad,;Mt AilloyAfl in your place of business, In additlon, while we hope you never experience a workplace injury, we went you to be prepared in the Went You need to report a claim. You can also download and printthe First Report of Injury document from the some web page. On the right side of the page you will locate th.e'First Report of Injury; which is YQ RE QNSIRILITYTOUSET NOTIFY US OF ALL EWR D C INJURIES as soon as the injury occurs, In addition, the information oaths loft side of the page is whatycu will nood when reporting a claim, including phone and fax numbers and rnalling address, If you do not have access to the Internet or the ability to printthe required posters, please contact your State Farm agent or call 1-055.264-22229for a claims ldtto be (nailed to you, Again,we thank you for choosing State Form to provide your business with Workers' Compensation Insurance, REV!♦1 ED & APPRQVEIa Prepared 05 f 20 / 2019 sa, Yz o-ir so iniws�iWNT [XVIxf()N Capytlghr. atsto rarm Muutof AutanwblIo nnsuronoo t:ompany, 2008 Inalodnssopyrlahtedmatorlaloflnsuranooaorvlaosanloa,Ioa•,wllhIto pormloslon. 4)�T NE n, VILLAREAL WORKERS COMPENSATION AND E%OYERS LIABILITY POLICY INFOR23»1229_FAC1 GE POLICY NO 92-GA-J3z4-6 SOVE AGE IS PR6VI1U D BY REPLACES N0, 92-EW-•f�1768-i TATP FARM FIR A D CASUALTY CVpMPANY PO Box 653925, Richardson TX 75g85-3925 NCCI CARRIER CODE NO, 14842 i, NAMED INSIYRED & MAILING ADDRESS S(A��NIIppVA Upp I FEIN 953083493 SANNAXANASC U DEL 92703�U168 SANTAI�IATCAANABL D STa 214A INSURED IS AN INDIVIDUAL COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE 2. ATETHOELINSUREbl6DMAIL.INGMAgl7RES52018 TOKOQ7/Cli:1A/ :fl 0 12:01 A.M. STANDARD TIME 3A. WORKERS GQM�PONSAfIbN LAWUOF�TNE SAAIEONE 06TH POLICCAAPPLICS TO THE B. UTO NIIB5PR�0ARTCH STAIT6ERS YLISO D INNJU R YTAgCeDEW I- I 'SO0DY00Rpkl HILCCIDENT BODILY INJURY BY DiISIEAS $ t,D440;0p0� EACH ACCIDENT C. EXCEPTShI TCMTINNUORAQFIEIRPARWATHWlUC WY ANDS UE S LISTEDSINU3ALL STATES D. C436CY0431DT004060 RSC0404NDWC0043*' WCOODOOOCW000AWC00AW0006 *EFFECTIVE 07/01/19 4, THE PREMIUM IOR TH ISPOLICYYTESILMDBE DETERPLANDS.BA MM OLURJANUALS OF _---' ____ REQ M ED BELOW IS SUBJECT TQ VERIFICATION AND CIIANIGE BY AUDIT, 4Ar!(7Y______ __ ________________"7ALME3MIMAIS' AN--REMD�IE100 LSXIUALTCD QIlEuNQS OLASSIFII;ATIONS NUAL REMUNERATION PION PREMIUM 8810ICAL 4 -- _ H~176,800 .40 p - 707 CLEROFFICE EMPLOYEESV- MOC4Y 8868 V1� ADU7(L7MO61L6RSGMODDLSS- pIPOFESSORS NOT TEACHERS OR PRUFESSIUNAL EMPLOYEES EC.MP1-0YERSULLIABIILITYOPIMNT$EASED TERRORISM 9740 44,200 REVIEWED & APP By Rizk MANnCLMrNT 221.000 77 .03 340 115 66 MINIMUM PREMIUM $ 500 CALIFORNIA TOTAL ESTIMATED ANNUAL PREMIUM $ 1,228 PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL STATE DEPOSITPREMIUM $ 1A228 FDSUCHARGE.00 SEE SURCHARGE OVERFLOW PAGE PREPARED 05/20/2019 WC 00 00 01 04-84 COUNTERSIONE WORKERS COMPENSATION AND EMP4.QYEA S LIAOILITY POLICY g SURC�IAR92EN lLQW PAGE 23-12?,9 PAC1 POLICY NO. 92-CAA-032A..0 IYXIRAR 925�RRCa ;UAiLTX �6ga�N�325 R (NFTy ASS�r�S� T11 pp S�INNM QENETI A0 REVIVED & APPROVED By Rt5 MANAGEMENT UVISION OCTRVIL20 F�AREAL PREPARED 05/20/2019 WC9900031ED 3-111 Important Information on flaw Your Workers' Compensation Premium Is Determined and the Attdit process When your policy was issued, the premium was based on an estimate of your business operations and your workers' payroll, At the end of the policy period, an audit will be performed to determine your actual payroll and business operations. We will be able to calculate the final Premium from this infgl•nnation. The Audit Process A review of your firlanccial records, such as payroll logs, general ledgers and tax returns will be required, A Mate Farm representative will contact you by mail, telephone or visit with you in person to obtain the Information. It Is to your benefit to have your accounting records set rip by employee and type of work they perform. We will also obtain a complete description of your business operations to confirm the classification codes on your policy are correct, We will assign the payroll to the classification code(s) that represent the type of work performed and apply the appropriate rating factor to determine your final premium,'T'he final audit prennlutn will be comparedto the esthnnated premium and a premium Adjustment Statement will be sent to you reflecting any change. please note that a significant change may require that we also adjust your current policy premium, Items That Affect Your Premium "AQkJ!wVA pwSq J fllcer -The remuneration used for each covered sole proprietor/partner/officer may be either a predetermined aannount, or actual remuneration* subject to a nninimum/maxinnum, "dt muneration means allpayroll and other forms of earning such as bonuses, txry anisstons, sick days, meals, and iodging, . Eenpl eq To nt)orgrvEiilplpye� j, l nn loy s • Actual remuneration paid to each employee. You may be respoinslble for temporary/leased employees regardless of the temporary, or leasing company's insurance arrangements. Use ofuicon radars - A Certificate of Insurance for Workers' Compensation coverage needs lobe obtained annually for every subcontractor you hire, Tf a subcontractor has no employees, a Certificate of Insurance for contractor's liability coverage needs to be obtained, If certificates are not obtained , the subcontractor and their employees may be considered as your employees for premium calculation, This could substantially increase your final prennlurn, Busilness 0 etatio,�n,,�, - The actual remi neratlon will be assigned to a classification code In aC rd.arice�ndustry rules as published by the National Council of Compensation insurance (NCGI) or specific guidelines as published byyour state, All a edit information provided will be kept coufidentied. If you have any questions concerning this information, please contact your state parm agent• The ire armation. coutafned tie this document outflnesgenerral a:ancepts. Inforireeir�t n required may vary by state and could be Impacted k f%JAWE y & APPROVED lay RIs MANAC,GMENr Division elate Pam P1ra and caaaalty Company aiuotninptonAL G9""t A t�• 1 , t-RMCINE R. VILIAREAL Bear commercial policyholder, Whether you're operating a business solo from your home or have multiple locations find empployees, it's Important to protect your business with what we call a "risk management" program, l stablisliing and maintaining a risk tn.anagement program: Shows concern for your employees' heolth and safety • May help mitrol losses due to Illness or Injury State Parnlahas tools and services to help you establish a program just right for your business or to complementwhat you're already doing, To learn how State Farrn may help you protectyour business, complete and return the card below, or visit statefarm,cou?, and click the insurance tab, then Business. On behalf of your local Slots Farm agent, we wish your conthnied suceess In man agingyour• business rislcsl Statte Parm Workers' C oinpanaation policyholders Some rederad and state laws place responsibility on employers to provide sate, healthful workplaces, so It's Important to: Know your location's governlmg authority Know which safety and health standards apply to your businvis I•lave and adhere to a program that compiles with applicable laws A risk managementprogram may help you! Manage insurance and olmrating costs Protect profits improve operating efticiemuy and productivity .Maintain product quailty Instill employee and customer confidence A Special Message to QarWorkers' Compensation Policyholders to C;alifornias State Farm's loss control consultation services are available at no additional cost to our policyholders. Workers" Compensatlom Insurance policyholders may register comments about the instirer's loss control consultation services by writing to: State of Callfornla Deportment of Industrial Relations Dlylilon of Occupational Safety and Health PA Box 420603 $an 'Francisco, CA 941.42 if interested in learning about this informatlon and service, please complete the information below and return to the indicated addressa State Parm I wurance Companies PO Box 8530 Richardson, TR 75085-3922 Aunt Businom lines Loss Control Unit Name Phone L----1 Address _ _ _,.. _ �_ > •Imail City , _ State.____. Zip_— -. 2i)&; Nurnher _ _ Agent_ Q AV pItUYE C)ryata may also call curl oss Control Unit at: 844 g92.828(, aretnail in c��lg jylptvpcaFMFNT DIVISIONfitex.conuand Iossorl.S3Aiaaae y h1 reLConl Santa Pane trroducas and service ot%riflas are 1101 intended to ba blelusiva uru11 poanntisi ara:ldentsamraes, mar awls l` iiW''i u�a warrant your compliance with federal, state, or fir? n , a..t __........«w, WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURAN09 POLICY WC 00 04 29 R (Ed,1"f f3} TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addreasoe the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk insurance Program Reauthorlxatlan Aal of 2015, It serves to notify you of certain Ilmitollons under the Act, and that your Insurance carrier Is charging a premium for losses that may ocour In the event of on Act of Torrorlem, Your policy provides coverage for workers compensation losses oaused by Act of Terrorism, Including workers compensation benefit obligations dictated by elate law. Coverage for such loesee Is still subject to all terms, definitions, oxolusions, and oonditlona in your pclloy, and any oppllooblo federal and/or state laws, rules, or regulallons. DOWtionsi The definitions provided In this ondoreament are based on and have the same meaning as the definitions In the Aot, It words or phrases not defined In this endorsement are defined in the Act,the definitions In the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took offset on November 26. 2oo2 and any nmondments (hereto, Including any amendments resulting from the Terrorism Risk Insurance Program Reautharixatlon Act of 2010. "Act of Terrorism" means any act that Is certified by lho Secretary or the Treasury, In consultation with the Secretary of Homeland Security, and the Attorney General of the United Motes ps meeting all of the following requirements: a. The act Is an not of terrorism, b, The not Is violent or dangerous to human life, properly or Infraslruoture, c, The oot resulted in damage wlthin the United States, or outside of the United States in the case of the premises of United Slates missions or certain air oarders or vessels. d. The act has been oommlt4by an Individual or individuals as part of an effort to 000roa the civilian population of the United States or to Influence the policy or effect the conduct of the United Stales Government by cooroion. "Insured Lose" mean& any loss resulting from an act of t.onorlanl (and, oxoopt for Pennsylvania, Including an act of war, in the case of workers compensation) that is covered by primary or excess property and caeuolty Insurance Issued by an Insurer If the loss occurs In the United $totes or st the pronlisos of United $totes missions or to certain air oarriere or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2016, and ending on December S1, 2020, an amount equal to 20% of our direct earned premiums, during, the Immediately preceding calendar year, Limitatton of Liability The Act limits our liability to you under this policy, If aggrogato Insured Losses exceed $100,000,000.000 in a calendar year and if we have met our Ineurer Deductible, we are not liable for the payment of any portion of the amount of Insured Lasses that exceeds $100,000,000,000; and for aggregate Insured Looses up to $100.000,000,000, we will pay only a pro rats share of such Insured Losses ae dotormfned by the Secretary of tho Treasury, Policyholder disclosure Notice 1, Insured Losses would be partleliy reimbursed by the United States Government. If the aggregate Industry Insured Losses oxooed; a. $100,000,000, with respect to such Insured Losses occurring In calendar year 201S. the United States Government will pay 06%of our Insured Loseas that exceed our Insurer Deductible. b, $t20,000,000, with respect to such Insured Losses 000urrino In calendar year 2010, the Unitod States Government will pay 04%of our Insured Lasaes that exceed our Insurer Deduotible. o. $140,000,000, with respect to such Insured Losses occurring In calendar yonr 2W, the United Stales Government will pay 83% of our Insured Losses that exceed our Insurer Doduotiblo. d, $100,000,000, with respect to such Insured Woos%occurring in calendar year 2010, the United States Government will pay 82% of our Insured Losses that exceed our Insurer Deductible, e, $180,000,000, wlth reepoct to such Insured Lossos occurring In calendar year 2 WN tta�d -ED Government will pay S 1% of our Insured Lossos that exceed our Insurer Deduot�� U &�Xm Div BlomR � At'` ENT C)IviioNf. $200,000,000. with respect to such Insured Losses occurring In calendar year 20�Yf,l'�ad Saralee Government will pay $0% of our Insured Losses that exceed our Insurer Deductible, u C,i 2 � 2019 ocopyrlght aata National soonoil an aompanoatlon InatIXanaa, Ina, All nights nesorved. �l e M1 . (EUgasaj"o �12ANC E R IL#AREAtn WO 00 04 22 0 WORKERS COMPENSATION AND CMPLOYi?tt8 LIABILITY INSURANCE POLICY (Ed, 1.16) 2, Notwithstanding Itom 1 above, the Vnitod Stales Government will not malio any payment under the Act for any pprtlon of Insured Lasses that Mead 4100,000,000.000, 3, The premium charge for the coverage your policy provides for Insured Losses is Included In the amount shown In Rain d of tho Information page or In the Schedule below. State Schedule pate Premium This ondorsoment changes the policy to which 11 Is attached and is olfecilve on the date losuod unless olhorwlao stated. (The information below to required only whon this endorsement le Issued subsequent to preparation of the policy,) Rodomomont Effective policy No, Insured Insuranps Company WC 00 04 22 B (Ed. 1.16) Endorsement No. Premium $ Countoraignod By @ copyright got National council on compansatlen insuranee, ruo. All nlghta rrelteNod. REVICWED &APPROVED BY RIS MANAGEMENT i)iV MON q T � l F1 NGN ft, vILLAR '