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HomeMy WebLinkAboutBENEVATE, INC. (3)INSURANCE ON FILE OCEA-2020-085-05-03 �v WORK MAY PR THIS THIRD AMENDMENT TO SAAS SERVICES AGREEMENT (this "Third Amendment")is made effective August 12, 2021, between Benevate, Inc ("Company") and the City of Santa Ana, California ("Customer"). - Uk ( A-% %Gt,, Voi 11) l S Ak) k RECITALS A. The Company and Customer entered into a SAAS SERVICES AGREEMENT dated May 12, 2020 and modified by First Amendment effective November 17, 2020 and Second Amendment effective May 11, 2021 (the "Agreement"), for the Company to provide hosted software for the administration and management of the Customer's housing and community development programs. B. The Customer has determined that it is necessary to again amend the Agreement with the Company to (i) add additional licenses and custom report to the Scope of Work of the Agreement (the "Additional Licenses") and (ii) increase the compensation of the Company for the Additional Licenses and Custom Report. C. The Company and the Customer desire to enter into this Third Amendment to (i) include the Additional Licenses, Custom Report, and (ii) increase the compensation of the Company for the Additional Licenses and Custom Report. AGREEMENT NOW, THEREFORE, in consideration of the foregoing recitals, which are incorporated herein by reference, the following mutual covenants and conditions and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Company and the Customer hereby agree to amend the Agreement as follows: 1. Per User Pricing. The Company shall provide the Licenses and build one Custom Report as set forth in Amended Exhibit D, attached hereto and incorporated herein by reference. 2. Compensation. The Customer shall pay Company Annual Recurring and One Time Implementation fees as set forth in Amended Exhibit D, attached hereto and incorporated herein by reference. 3. Effect of Amendment. In all other respects, the Agreement is affirmed and ratified and, except as expressly modified herein, all terms and conditions of the Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this instrument as of the date and year first set forth above. Company " � Jaso usnak, President CITY OF SANTA ANA, CALIFORNIA: Kristine Ridge, City Manager Recommended for Approval: A r d as t form: Attest: �q' /i�IryY tJ \ I -_ w - Steven A. Mendoza Ryan odg Daisy Gomez It Director - CDA Assist City A omey Clerk of the Council AMENDED EXHIBIT D Per User Pricing Additional user licenses may be purchased, pro-rata to the Initial Service Term, based on the pricing table below. TOTAL LICENSES PRIOR TO 3rd AMENDMENT: 17 INCREASED TOTAL LICENSE COUNT BY: 28 TOTAL ADMINISTRATIVE LICENSES: 45 Jeighborly Software Per Administrator Fee (Users 1-10) $200 Monthly alr Jeighborly Software Per Administrator Fee (Users 11-20) $150 Monthly 3 Jeighborly Software Per Administrator Fee (Users 21+) $100 Monthly 25 Technical Support Included Hosting/Security in Microsoft Tier IV Data Center Included Data Strorage, Backup and Recovery Included ANNUAL TOTAL: §35,400.00 9 month lAuoust 17. 7f171 - AAav 17 7n771 Pan.PATA TnTAe • t7A �cn nn Software Implementation Per Program' $1,500 one Time $0.00 - Software Configuration to Client Design Included - Administrator Training (Virtual) Included -Administrator Guide Included - Travel (onsite training will be revised post COVID-19) $800 Per Trip 0 $0.00 (Optional) 'Data Migration of Active Loans (Minimum $2,600) 1 $2.50 Per Loan: n/a Custmam Report Buildout $2,000 - One Time : 1 $2,000.00 (Optional) -:Craftsman Book Spec. Database -Cost : Estimating $500 Annually- n/a a - Includes configuration for the fottowing programs: ONE TIME IMPLEMENTATION TOTAL $2,000.00 3rd Amendment TOTAL: $28,550.00 1. Recurring fees are invoiced annually in advance. 2. Implementation fees are invoiced at engagement Fro GCIDP R. VilUraal noneMialmpD.nama.wan..i on CERTIFICATE OF LIABILITY INSURANCE DATE (MMID13=17Y) 01/1312021 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 ALTERTHE COVERACEAFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTR\CT BETWEEN THE ISSUING INSURERRS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANTH the eme Boom holder la an ADDITIONAL INSURED, the Folic,den ..at have ADDITIONAL INSURED proralnns or be endorsed If SUBROGATION IS WAIVED, subleeem thelernm and conditions of the paltry, certain policies may re9ube an endorsement. A statement on this certificate does net confer rights to the cerlNenle bolder In lieu of such endorsen,enno. PRODUCER CONTACTNAME: FoanderShleld, LLC PHONE (AW No ESQ: 646-854-1058 122 W 26tb Street, Had Floor Nov York, New York, 10001 E-MAIL ADDRESS: c01(eJfoundarshlelJ.com INSURERS) AFFORDING COVERAGE FAIL INSURER A: HARTFORD UNDERWRITERS INS CO(HARTFORD) 30104 INSURED INSURER D: ILLINOI3 ONION INSURANCE CO 27960 INSURER C : AXIS INSURANCE COMPANY 37173 eenevete INSURER Be 342J Pledmon[ Rd NE aHenla, Ceorgla, JDJ05 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR L'1'R TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,DD0,000.00 CLAIMS MADE OCCUR DAMAGETORENTED $1,D00,000.00 PREMISES (Ea a ativi ence) SUED EXP (Any one person) $ID,000.00 A GENT AGGREGATE LIMIT APPLIES PER: �! S ;b-y IM IDSBAAJSR MOB12021 01/182022 PERSONAL&ADV INJURY $1,000,000.00 f TPOLICY Cryyyry PROJECT tE,I LOC GENERAL AGGREGATE $2,000,000.00 PRODUCTS-COMP/OPAGG $2,000,000.00 y jOTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,00D.00 , j ANY AUTO (Ea ceeident) BODILY INJURY (Per person) A OWNED AUTOS 'n ti � YSCHEDULI ONLY LJ x•�" t, j IDSBAAJIMSR pi110f1021 M/1&2022 BODILY INJURY (Per tom✓ ! °NON -OWNED AUTOS yyi HlltED AUTOS ONLY ONLY acddenry PROPERTY DAMAGE (Par accident) )� UMBRELLA LIAR jr- EXCESS LIAe EncM1 act arunce $2,000,0DD00 B .-y' CLAIMS-MADE G72503910001 01/12021 01/12022 Aggr am $J,000,ODo.00OCCfR WORKERS COMPENSATION AND EMPLOYERSLIABILITY PER STATUTE n.h ANTE ROPRMTORTARTNER/EXECUTIV YIN OFFICERIMEMBER EXCLUDED? N OTHER E.L. EACH ACCIDEN (Mandatory In Nin [fyes,deu,11monder DESCRIPTION OF OPERATIONS below WA �..: ,,. E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT C Cybur Liabillty,Media Liabi111y,Errors& Omissions s.•' i�2 ITTN-200275-01 011IW2021 DIJIM022 53,000,000 per am $3,000,000 in ago C Social Engineering F �. ITTN-200275-01 QVISCHU1 DI/I82022 $100,000peroce $100000hugg A Property F. i—! IDSBAAJIMSR 01/IB/2021 011182022 512000.00 DPI• $1,000 deductible fn 6.i in DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Acrid .nal RemmM Scbamle, may he nmmhed If non —pare Ir reamers) CltyofSanln Ame,m][mars,ngenrs,employees, and voluukera are named as emotionally Soared on thl"thy pnnmmr too". ma—l''agrc'.mzt or memornndum of understanding Such b,mnn¢as is traded by this policy sbnll be prlmargand eny Insurance stinted by Cal, almll he ¢sera, mal nanennhNulm'. C"llOeate of Insurance Wall provide thirty (30) day prle, n losm notice ofemseellatm.. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE City of Santa Ana THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ithk Menagcment Divisiva 20 Civic Center Plaza Seam non, CA 92702 AUTHORIZED REPRESENTATIVE /J�G�•, " OF 198E-2014 ACORD 25 (2016/03) The ACORD name and logo are registered narks of ACORD thWekManagowdD[YIeirt R REVIEWED&APP!R,OVED BY. � ��aaa.c�.E.e �, Ki�LAMlaE Bids Management AnoWt r�T Uttestchester A Chubb Company Illinois Union Insurance Company Excess Liability Insurance Policy Declarations This Policy is issued by the stock insurance company listed above (herein "Insurer"). UNLESS OTHERWISE PROVIDED IN THE FOLLOWED POLICY, THIS POLICY IS A CLAIMS MADE POLICY WHICH COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD. PLEASE READ THIS POLICY CAREFULLY. Policy No. G72503910 001 Renewal Of Item 1. Insured Company Benevate, Inc Principal Address: 3423 Piedmont Road NE Atlanta, Georgia 30305 Item 2. Coverages Provided: Excess Privacy and/or Security Liability, Technology Liability Item 3. Followed Policy: AXIS PRO Technology and Professional Services Liability Insurance Policy AXIS 1010001 0117 Insurer: AXIS Insurance Company Policy Number ITTN-200275-01 Item 4. Policy Period From 12:01 A.M. 01/18/2021 To 12:01 A.M. 01/18/2022 (Local time at the address shown in Item 1.) Item 5. Premium $ 4,000 Policy Premium $ 4,000.00 Total Amount Due Item 6. Limit of Liability/Aggregate Limit: $ 2,000,000 for all Loss under all Coverages combined. Item 7. Underlying Policy Limits/Attachment Point: $ 3,000,000 Item 8. PENDING & PRIOR LITIGATION DATE: 12/09/2015 This Policy is intended to follow the Pending & Prior Litigation Exclusion of the Followed Form, subject to the date indicated above. PF-20440 (04/14) 0„ RAMana9MKDM81an �1 4 RwEWEo&APPRavED BY: �'-----� R(sia ktanngemene Anatyst Item 9. NOTICE TO INSURER A. Notice of Claim, Wrongful Act or Loss PO Box 5119 Scranton, PA 18505-0549 First Notices Fax: 215.640.5040 or 1.877.746.4671 General Correspondence Fax: 1.866.635.5688 First Notices Email: ChubbClaimsFirstNoticela Chubb.com B. All other notices: Westchester Specialty Group Attention: Professional Liability Dept. Royal Centre Two, 11575 Great Oaks Way Suite 200 Alpharetta, GA 30022 THESE DECLARATIONS, TOGETHER WITH THE COMPLETED AND SIGNED APPLICATION AND THE POLICY FORM ATTACHED HERETO, CONSTITUTE THE INSURANCE POLICY. Date: 01/14/2021 MO/DAY/YR. PF-20440 (04/14) 53JOHN J. LUPIGA. President Authorized Representative -„ysn, Riaki<MnagenatenlWe�on Rt1nEWEo&Ameovai Bv: WIR MManacgetnent.Anallyst SIGNATURES Named Insured Endorsement Number Benevate, Inc Policy Symbol Policy Number Policy Period Effective Date of Endorsement G72503910001 01/18/2021 to 01/18/2022 01/18/2021 Issued By (Name of Insurance Company) Illinois Union Insurance Company Insert the policy number. The remainder of the Information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THE ONLY SIGNATURES APPLICABLE TO THIS POLICY ARE THOSE REPRESENTING THE COMPANY NAMED ON THE FIRST PAGE OF THE DECLARATIONS. By signing and delivering the policy to you, we state that it is a valid contract. ILLINOIS UNION INSURANCE COMPANY (A stock company) 525 W. Monroe Street, Suite 400, Chicago, Illinois 60661 WESTCHESTER SURPLUS LINES INSURANCE COMPANY (A stock company) Royal Centre Two, 11575 Great Oaks Way, Suite 200, Alpharetta, GA 30022 REBECCA L.COLLINS, Secretary LD-5S23i (03/14) ull .�u ��UjjltrQ�" �. .„,�,rnnIQIQUI�II Authorized Representative Chubb. Insured' Nwn WManagenentDielslon RoAEWED&APPROVED BY., Risk Management Analyst ACCJFLL7� CERTIFICATE OF LIABILITY INSURANCE DA05/21'/202YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy((es) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Doug Jones Justworks c/o Artex Risk Solutions, Inc. 8840 E. Chaparral Rd.; Suite 275 CONTACT Justworks Customer Success NAME:ME: PHONE FAX QUIT (888 ) 5341711E,MAlc,Ne1: ADDRIESS: support@justworks.com INSURERS AFFORDING COVERAGE NAIC H Scottsdale, AZ 85260 INSURER A: American Zurich Insurance Company- 40142 _ INSURED Justworks Employment Group LLC Labor Contractor, for cc -employees of: Benevate, Inc. INSURER B : _ INSURERC: INSURER D 55 Water Street 291h Floor New York, NY 10041 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 20NY0171006023 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSD MD POLICYNUMBER POLICYEFF MMIDDNYYY POLICY EXP MM/DDiYTYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE1:1 OCCUR EACHOCCURRENCE $ D MAGETORE PREMISES E occurrence $ MED EXP Any one person) $ PERSONAL &ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: POLICY❑JECTPRO- ❑ LOC GENERALAGGREGATE $ PRODUCTS-COMPIOP AGO $ $ OTHER: AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accidentl $ BODILY INJURY (Per person) _ $ ANY AUTO OWNED F7 SCHEDULED AUTOS ONLY AUTOS H BODILY INJURY P (Per accIdent) $ HIRED F7 NON -OWNED AUTOS ONLY AUTOS ONLY PROPEIff DAMAGE Per accidsnl $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ _ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERSLIABILITY- YIN X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2000,000 A OFFIC ANYPRORPMEMBEREXCLU EO?ECUTIVE ❑ N/A WC 49-71-166-01 06/01/2020 06/01/2021 EL DISEASE - EA EMPLOYE _ $ 2,000,000 (Mandatory In NH). If yes, describe m dor DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ 2000,000 Location Coverage Period: 06/01/2020 06/01/2021 Client# 25327-GA DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Benevate, Inc. Coverage Is provided for 3423 Piedmont Road NE Suite 216 only those co -employees Atlanta, GA 30305 of, but not subcontractors to: Benevate, Inc, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3423 Piedmont Road NE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suite 216 ACCORDANCE WITH THE POLICY PROV Atlanta, GA 30305 I AUTHORIZED REPRESENTATIVE y !•� sun RAMarn mentDWIon yry q REVIEWED SpAPPPROVED BY.' �-' tialq Management Analyst ©1988-2015 ACORD C � < _ - _ , . -. ACORD 25 (2016/031 The ACORD name and loco are registered marks of ACORD Francine R.-olyltallysignEdby Frundne R.VllllamaI Villareal DUE: 2021.00.1716:3024-07'00' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 08/11/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER Doug Jones (Justworks) do Artex Risk Solutions, Inc. P.O. Box 13838 CONTACT NAME: Justworks Customer Success PHONE FA% _(AL6.NP. EA (888) 534-1711 A/( C No): ADDRESS: support@justworks.com INSURERS AFFORDING COVERAGE NAIC M Scottsdale, AZ 85267 INSURER A: American Zurich Insurance ComDanV 40142 INSURED Justworks Employment Group _LC Labor Contractor, for co -employees of: Benevate, Inc. INSURER B : INSURER INSURER D PO Box 7119 Church Street Station New York, NY 10008-7119 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:21NY0171006023 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MMIDDIYYYYI POLICY EXP IMMIDDIYYYYTLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ PREMISES TD RE TED S La occurrence $ MET EXP (Any one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PRO- ❑ ECT OC PRODUCTS - COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea scald ad $ BODILY INJURY (Par person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY FlUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY YIN _ PER OTH- X STATUTE I ER E.L. EACH ACCIDENT $ 2000,000 A ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? ❑ NIA WC 49-71-166-02 06/01l2021 06/01l2022 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 (Mandatory In NH) f yes, describe under DESCRIPTIONOFOPERATIONSbelow E.L. DISEASE -POLICY LIMIT —- $ 2,000,000 Location Coverage Period: 06/01/2021 06/01/2022 Clientlf 25327-GA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is rer ul red) Coverage is provided for Benevate, Inc. only those co -employees 3423 Piedmont Road NE Suite 216 of, but not subcontractors Atlanta, GA 30305 ta: City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE dba: Community Development Agency THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROV Santa Ana, CA 92701 'rRIti%v. PJAManagemanaDfvlelan AUTHORIZED REPRESENTATIVE yy x @ REVIEWED&APPRDVE7BY., Furl ry `/ ice' !✓ RNk ManagemzmAnalySt ©1988-2015 ACORD C .a?_ ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD