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HomeMy WebLinkAboutHEALTHY OUTCOMES, INC. DBA BALANCING ACTINSURANCE Ors'!U WORK ddpv -a`" f r. A-2021-215 N.01. ozZ DEC 17 2021 FM SR(Thavlholn ��o�Tt Mt(4YVV SUBSCRIPTION AND SUPPORT AGREEENT FOR City Santa Ana, CA This Subscription and Support Agreement (the "Agreement"), is hereby entered into as of November 3, 2021 (the "Effective Date') by and between City of Santa Ana, CA, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California. ("Client') and Healthy Outcomes, Inc., DBA Balancing Act, Iocated at 7897 E. 20 Avenue, Denver, CO, 80238 (`Balancing Act"). Client and Balancing Act are collectively referred to as "the Parties" and individually referred to as "Party." WHEREAS, Balancing Act is in the business of developing web software and sites capable of hosting public policy simulations and related projects promoting an exchange of information and ideas for use by governmental and other entities; WHEREAS, Client desires to subscribe to access Balancing Act's proprietary web applications to be used for public education and engagement, and NOW, THEREFORE, in consideration of the foregoing recitals and mutual covenants contained herein, the parties agree as follows: I. SCOPE OF ENGAGEMENT. A. Subscription Agreement. Balancing Act shall provide Client with access to the products and features of the Balancing Act web application specified in Exhibit A to this agreement and agrees to provide all of the technical, administrative and professional support services necessary to perform this Agreement. Client is granted a non-exclusive, non -transferable, and revocable license to access and use the Balancing Act website. Client shall have the right to test and approve the application prior to it going live. B. Support Services. Balancing Act shall perform and provide certain support services to Client in accordance with the terms and conditions of this Agreement and the SOW (the Services described under "Support Services", the "Support Services'). If Client hereafter requests additional services not described on Exhibit A ("Additional Services') or Exhibit B ("Proposal"), and Balancing Act is willing and able to provide those Additional Services, the parties shall mutually agree upon and execute one or more additional SOWS that contain the terms and conditions of the Additional Services to be performed. Each such 1 SOW shall be attached to and incorporated into this Agreement as an Exhibit through an Amendment to the Agreement signed by both Parties. Except as otherwise provided, any Additional Services to be performed by Balancing Act shall be subject to the terms of this Agreement. C. Fees. Client shall pay Balancing Act pursuant to the Fee Schedule selected by Client and attached hereto as Exhibit "C." The total amount to be expended during the Tenn of this Agreement shall not exceed $55,000. 2. FEE PAYMENT AND TINTING. A. Fees. In consideration of Balancing Act's granting of access to the Site and performance of the Services, hereunder, Client shall pay Balancing Act fees, and reimburse Balancing Act for expenses, each in the amounts and in accordance with the payment terms and conditions specified in this Agreement and on Exhibit C attached hereto (collectively, the "Fees"). B. Late Payment. Except with respect to amounts disputed in good faith, all amounts due under this Agreement, if not paid within 45 days of the due date, shall be considered late and shall accrue interest at the rate of one and one-half percent per month or the highest amount allowed by applicable law, whichever is less. Should collection activities become necessary, Client agrees to pay all fees relating to said activity. C. Client's Failure to Pay. Client's incurring of a late payment (as determined in accordance with Section 2(B)) shall be considered a material breach of this Agreement. As such, until such breach is cured by way of full payment, Balancing Act may (i) refuse to deliver the reports, materials, and other deliverables that it would otherwise be obligated to deliver hereunder, (ii) cease performance of any Services, (iii) issue a notice ofnon-payment to Client, which, if not satisfied within 15 days after the receipt thereof, shall constitute grounds for Balancing Act to terminate this Agreement or the SOW applicable to the Services. These rights are not exclusive, and Balancing Act reserves its right to seek any other rights or remedies provided in law or equity. D. Taxes. All amounts payable to Balancing Act as specified herein are in United States dollars. Client shall be responsible for any taxes imposed on the transactions contemplated by this Agreement, including all sales, use, value-added, excise and other similar taxes (but specifically excluding taxes in, or measured by, Balancing Act's income), 2 3. CLIENT OBLIGATIONS. Client shall be responsible for the accuracy of all data utilized by Balancing Act under this Agreement and shall comply with all laws and governmental regulations affecting its use, including all open and public records laws. Balancing Act shall have no responsibility to advise Client about the applicability of any laws or regulations that may apply to this Agreement. 4. SERVICE LEVEL AGREEMENT A. S_ Mort Services. (i) Balancing Act's web platform will be operational and available to Client at least 99.5% of the time in any calendar month (the "Balancing Act Application SLA"). If Balancing Act does not meet the Balancing Act Application SLA, Client will be eligible to receive the Support Service Credits described below: Uptime Percentage Support Service Credit (Days) < 99.5% - >= 99.0% 3 < 99.0%->=95.0% 7 < 95.0% 15 (ii) Service Credit Request. In order to receive any of the Support Service Credits described above, Client must notify Balancing Act within 30 days from the time Client becomes eligible to receive a Service Credit. Failure to comply with this requirement will forfeit Client's right to receive a Service Credit. (iii) Maximum Service Credit. The aggregate maximum number of Support Service Credits to be issued by Balancing Act to Client for all Downtime that occurs in a single calendar month shall not exceed fifteen days of Service added to the end of Client's term for the Service. Support Service Credits may not be exchanged for, or converted to, monetary amounts. (iv) Application SLA Exclusions. The Balancing Act Application SLA does not apply to any services that expressly exclude this Balancing Act Application SLA or any performance issues: (i) caused by factors described in the "Force Majeure" section of the Agreement; or (ii) that resulted from Client's equipment or third party equipment, or both (not within the primary control of Balancing Act). 3 5. TERM. A. Term. This Agreement shall commence on the Effective Date and be effective for three years. B. Option to extend. Client shall have the option to extend for up to two one-year renewals at the same yearly price as during the Term, in the City's sole discretion, exercisable through a writing executed by the City Manager and City Attorney, C. Termination. This Agreement may be terminated by the Client or Balancing Act upon thirty (30) days written notice of termination. In such event, Balancing Act shall be entitled to receive and Client shall pay compensation for all services performed by Balancing Act: prior to receipt of such notice of termination, except, for work which fails to meet the required standard of performance. D. Early Termination Fee. The yearly fee.tinder this contract is based on a three- year term and as such is heavily discounted., If Client terminates before the completion of the three year term, Client agrees to pay an early termination fee of $2;000 and an amount equal to the difference between the discounted fee and the regular fee for each year prior to notification of termination. The difference between the discounted fee and the regular fee is $2,000 per year, 6. OWNERSHIP AND USE OF THE MATERIALS, USER CONTENT A. Creative Materi s, 'The Parties acknowledge and agree that an integral part of the services is the creation of the Balancing Act application for Client, which includes the development of certain information, content, text, graphics, logos, photos, videos, software and other items, as well as their selection and arrangement ("Creative Materials"), Such Creative Materials are protected by copyrights, trademarks, patents, trade secrets and other intellectual property and proprietary rights, and Balancing Act shall be considered the author of such Creative Materials and retains all right, title and interest in and to such Creative Materials. Client's rights to use the Creative Materials are limited to use solely in connection with this Agreement, and the rights and obligations granted hereunder. Any rights granted to Client under this Agreement to use the Creative Materials shall cease upon the termination of this Agreement. B. User Content. The Parties acknowledge and agree that the user content generated on the Balancing Act website by others who are not parties to this Agreement is not owned by either Balancing Act or Client but can be used by either Party for 4 promotional purposes or any other purpose during and after the term of this Agreement. Balancing Act acknowledges that the Client can and will retain the right to use any user content and the deliverables under this Agreement for any and all purposes related to the general business of the Client. 7. LIMITATION OF LIABILITY; DISCLAIMER OF WARRANTIES AND LIABILITY FOR ACTIONS OF THIRD PARTIES. A. Except for the terms and conditions set forth in this Agreement, Balancing Act makes no express or implied warranties about the performance of Balancing Act, including warranties of merchantability or fitness for a particular purpose. B. Neither party shall be liable for false or'defamatory statements, either orally or in writing, made by others who are not parties to this Agreement. 8. INSURANCE. Vendor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with products and materials supplied to the Entity. The cost of such insurance shall be borne by the Vendor. A. MINIMUM SCOPE AND LIMIT OF INSURANCE Coverage shall be at least as broad as Insurance Services Office Commercial General Liability coverage (occurrence Form CG 00 01) and include products coverage. (1) ]WInimuna Llmits of Insurance Coverage shall be at least as broad as Insurance Services Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injuryand personal & advertising injury with limits no less than $1,000,000 per occurrence.'If a gencralaggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the requiredoccurrence limit. If the Vendor maintains broader coverage and/or higher limits than the minimums shown above, the Entityrequires and shall be entitled to the broader coverage and/or the higher limits maintainedby the contractor. Any available insurance proceeds in excess of the specified minimum limits ofinsurance and coverage shall be available to the Entity. (ii) Sedf-Iusured Retentions Self -insured retentions must be declared to and approved by the Entity. The Entity may require theVendor to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policylanguage shall provide, or be endorsed to provide, that the self -insured retention may be satisfied by either the named insured or Entity. B. OTHER. INSURANCE PROVISIONS The insurance policies are to contain, or be endorsed to contain, the following provisions: (i) Additional Insured Status The Entity, its officers;.officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Vendor including materials, parts, or equipment fiunished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Vendor's insurance at least as broad as ISO Form CG 20 10 1185 or if not available, through the addition -of both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; and CG 2037 if a later. edition is used). (ii) Primary Coverage For any claims related to this contract, the Vendor's insurance coverage shall be primary insuranoecoverage at least as broad as ISO CG 20 01 0413 as respects the Entity, its officers, officials, employees, and volunteers. Any insurance or self-insurance maintained by the Entity, its officers, officials, employees, or volunteers shall be excess of the Vendor's insurance and shall notcontribute with it. (M) Notice of Cancellation Each insurance policy required above shall provide that coverage shall not be canceled, exceptwith notice to the Entity. (iv) Acceptability of insurers Insurance is to be placed with insurers authorized to conduct business in the state with a current A.M. Best's rating of no less than A: VII, unless otherwise acceptable to the Entity. (v) Verifcadon Insurance including all ra uq iced amendatory endorsements (or copies of the applicable policy language effecting coverage required by this clause) and a copy of the Declarations and Endorsement Page of the CGL policy listing all op licy endorsements to Entity before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive the Vendor's obligation to provide them. The Entity reserves the right to require complete, certified copies of all required insurance policies,including endorsements required by these specifications, at any time. (vi) Waiver of Subrogation Vendor hereby grants to Entity a waiver of any right to subrogation which any insurer of said Vendor may acquire against the Entityby virtue of the payment of any loss under such insurance,Vendor agrees to obtain any endorsement that maybe necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the Entity has received a waiverof subrogation endorsement from the insurer (vii) Special Risks or Circumstances Entityreserves the right to modify these requirements at any time, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. 9. ASSIGNMENT. Either Party may assign all or a portion of its rights or obligations under this Agreement but only with the express written consent of the other Party. 10. CONFIlDE' NTIALITY. During the term of this Agreement, each party (the "Disclosing Party") may provide the other (the "Receiving Party") with certain confidential and proprietary information ("Confidential Information"). Confidential Information includes, but is not limited to, (a) the Deliverables under this Agreement, (b) all business, financial and technical trade secrets, (c) any written information which is marked "Confidential", and (d) any information which is orally disclosed, identified as confidential at the time of disclosure and confirmed in writing as being confidential within 30 days thereafter. Confidential Information shall not include information that. (a) is publicly known at the time of its disclosure; (b) is lawfully received by the Receiving Party from a third party not under an obligation of confidentiality to the Disclosing Party, or (c) is published or otherwise made known to the public by the Disclosing Party. The Receiving Party will refrain from using the Disclosing Party's Confidential Information except to the extent necessary to exercise its rights or perform its obligations under this Agreement. Except as required by law, including the California Public Records Act, the Receiving Party may not disclose the Disclosing Party's Confidential Information to any third party, other than its affiliates or representatives who have an .absolute need to know such Confidential Information in order for the Receiving Party to perform its obligations and enjoy its rights under this Agreement, and only if such persons are informed of and are subject to the provisions of this Agreement. The Receiving Party remains linable for any unauthorized use or disclosure of the Confidential Information by any such representative or affiliate. 11. WEB SOFTWARE AND SITE TERMS OF USE AND PRIVACY POLICY. Balancing Act shall include on the Balancing Act website its privacy policy ("Privacy Policy") that applies to the activities of Balancing Act and the users of Balancing Act, including the use of users' personal information. Client represents that it has read and is familiar with the Privacy Policy and, to the extent applicable, shall govern itself in accordance therewith. 12. INDEPENDENT CONTRACTOR. Client and Balancing Act intend at all times to be independent contractors. Neither party is an employee, joint venture, agent or partner of the other, nor is either party authorized to assume or create any obligations or liabilities, express or implied, on behalf of or in the name of the other. The employees, methods, facilities and equipment of each Party shall at all times be under the exclusive direction and control of that Party. 13. GOVERNING LAW AND VENUE: This agreement shall be construed in accordance with and governed by the laws of the State of California and any claim or lawsuit brought to enforce the terms of this Agreement shall be brought in the state or federal courts serving City of Santa Ana; CA. 14.. FULL AUTHORITY. The person agreeing to the terms and conditions of this Agreement states and affirms that they have the full authority of Client to enter into and execute this Agreement. (Remainder of This Page Intentionally Left Blank; Signature Page Tollows.J E3 A-2021-215 IN WITNESS WHEREOF, CLIENT and BALANCING ACT have executed this Agreement as of the Effective Date. ATTEST: Daisy Gomez Clerk of the Council APPROVED AS TO FORM: SONIA R.CARVALHO City A rg By: Rya dge Assis t ity Attorney CITY OF SANTA ANA Kristine Ridge Date City Manager RECOMMENDED FOR APPROVAL: k-Ll r ,m Oct 19, 202I Kathryn Dawns (Oct 19.202112.14 PDT) Kathryn Downs Date Executive Director Finance and Management Services BALANCING ACT 7897 E. 24" Avenue, Denver, CO, 80238 10/13/2021 Chris Adams President Date EXIIIBIT A SUBSCRIPTION AND SUPPORT FOR SUBSCRIPTION, SUPPORT AGREEMENT BETV1rEEN BALANCING ACT AND the City of Santa Ana, 1. Client Information. Name: City of Santa Ana, CA Contact Person: Waldo Barela Phone:714-647-5428 Email: wbarola@santa-ana.org 2. SUPPORT SERVICES A. Balancing Act staff will provide one (1) training session via web conference for client staff. The training session will cover the following items: i) Setting up site, general orientation, strategic advice ii) Unlimited technical support and help understanding how to use features B. Balancing Act staff will be reasonably available during business hours and days to provide technical support and strategic advice, as requested. 3. SUBSCRIPTION AGREEMENT A. Design and Launch of the Site (a) i) B. Live Site (s) ii) iv) Client will have access to design and launch Site (s) beginning on the date of execution of the agreement. The Site (s) shall include the Balancing Act Simulate for Budget, Prioritize and Taxpayer Receipt.products. Client is responsible for selecting and uploading all content specific to its intended use of the Balancing Act products, including categories, subcategories, supporting information, additional details, numerical amounts, pictures, graphs or videos. Client is solely responsible for the time and cost associated with content creation and inputting. 1 4. SUPPORT SERVICE, S A. Administration and Site Support i) Balancing Act will provide up to two (2) hours per live site each month of Site administration, maintenance and support, including Client and user support during the Term. Support Services include, but may not be limited to the following; • General user support (password reset, site navigation issues, site utilization questions, etc.) ii) Any Support Services requested by Client other than Site administration, maintenance and support will be considered custom . development and billed to client as outlined in Exhibit C, 2 Exhibit B fialancingAct Proposal for Santa Ana, CA Balancing Act is a suite of tools designed to educate and engage residents about a local government's financial issues. Full Suite of Budget Engagement Software: • Simulate: this tool provides away for a government to frame tough financial tradeoffs and puts residents in the shoes of policymakers. It offers several different ways to interact with budget items and produces detailed, visual reports. Simulate is most often used for the general fund, but can also be used for capital budgets or special purposes, such as ARPA funding. • Prioritize: this tool offers a simple, visual way to present projects and costs. Government sets an overall budget and users select projects up to the specified amount, and then rank order them. The report provides weighted and unweighted results and can identify top projects based on three different voting techniques, including instant runoff. This is well suited to ARPA outreach, capital projects, and participatory budgeting. • Taxpayer Receipt: this app asks a few questions to generate an estimate of taxes paid and then creates a "receipt" showing how much a resident pays for each service. It is a way of demonstrating the value that government provides. Annual Subscription: Balancing Act is available as an annual subscription that includes all three tools, as well as unlimited subscription to Analytics: which gives you detailed insight into who is using the simulation and how they would balance tradeoffs, and Meeting Mode: which modifies Balancing Act for use in face-to-face or online synchronous meetings. Onboarding and unlimited technical support are included. Balancing Act is a SaaS product and requires no installation. Contract Duration: Three years at $10,000 per year (five-year rate), with two one-year optional renewals (at City of Santa Ana's discretion) at $10,000 per year. Contact: Amy Flynn amy@abalancineact.com 415.294.8787 Healthy Outcomes, Inc., DBA Balancing Act Chris Adams, President 7897 E. 24th Ave. Denver, CO 80238 303.877.0111 TaxpayerID# 84-1452641 Proposal Valid through 11/30/21 EXHIBIT C FEES FOR SUBSCRIPTION, SUPPORT AGREEMENT BETWEEN BALANCING ACT AND City of Santa Ana DATED September 19, 2021 The following is a summary of the Fees associated with the Services provided by Balancing Act hereunder. 1. Licensing Fee (published budget) i, Subscription fee is $10,000 per year. Invoice will be sent for the yearly licensing fee within 30 days of the effective date of the contract and every year at approximately the same time thereafter for the duration of this Agreement. Invoice for any agreed - upon additional services will be sent within 15 days of delivery. 2. General a, Except as otherwise provided herein or in an applicable SOW, all Fees due to Balancing Act will be payable within 30 days of receipt of the applicable invoice. b. All payments of the Fees must be made by cash or cash equivalent to Balancing Act at 7897 E. 24t' Avenue, Denver, CO, 86238 or by ACH. Credit card payment can be arranged, but may incur a 3% fee. 2021 BALANCING ACT RATE SCHEDULE AND REIMBURSEMENT SCHEDULE FOR "ADDITIONAL SERVICES" AND CUSTOM DEVELOPMENT Effective January 1, 2021 HOURLY RAT • S H •D rL +• Description Rate in USD Principal Staff $200 / how Custom Development $180 / hour Customer Success $150 Support Staff $60 / hour These rates listed above are valid for the initial Term of this Agreement, and Balancing Act may, as a condition to agreeing to any extension of the Term, require that the rates be adjusted. 11.03.21 Balancing Act Agreement w Exhibits Signed by Legal Counsel and BA 1 Final Audit Report 2021-10-19 Created: 2021-10-19 By: Kristin Andrade (kandrade@santa-ana.org) Status: Signed Transaction ID: CBJCHBCAABAAsfV7WFFL1cb6joNP5Fi-bz7GZ3mg3JAF t111.03.21 Balancing Act Agreement w Exhibits Signed by Legal Counsel and BA 1" History Document created by Kristin Andrade (kandrade@santa-ana.org) 2021-10-19 - 7:09:00 PM GMT- IP address: 98.153.69.210 C� Document emailed to Kathryn Downs (kdowns@santa-ana.org) for signature 2021-10-19 - 7:09:27 PM GMT Email viewed by Kathryn Downs (kdowns@santa-ana.org) 2021-10-19- 7.14:95 PM GMT- IP address: 98.153.69.210 6© Document e-signed by Kathryn Downs (kdowns@santa-ana.org) Signature Date: 2021-10-19 - 7:14:42 PM GMT -Time Source: server- IP address: 98.153.69.210 Agreement completed. 2021-10-19 - 7:14.42 PM GMT Adobe Sign Digitally signed by Francine R. Francine R. Villareal Villareal ACCARa• CERTIFICATE OF LIABILITY INSURANCE Ill 1 11/9/2021 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 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 TAPCO- KL (5576) PO Box 286 Burlington, NC 27216 CONTACT NAME PHONE (A/C No, Ext): FAX (A/C No): EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED HEALTHY OUTCOMES INC. 7897 E 24TH AVE DENVER, CO 80238 INSURER A: United States Liability Insurance Company 25895 INSUREB B: INSURER C: INSURER D: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDL INSR SUBR MD POLICYNUMBER POLICY FEE (MMODNYYY)(MWDD/YVYY) POLICY EXP LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR MTK1565488A 3/13/2021 3/13/2022 EACH OCCURENCE $1.000,000 RAMR� .occurrr ence) $WO,000 MED EXP (Any one person) $10,000 PERSONAL& ADV INJURY GEN'L X GENERALAGGREGATE $2,000.000 AGGREGATE LIMIT APPLIES PER POLICY FPRO- IFCTLOC PRODUCTS-COMP/OP AGG AUTOMOBILE LIABILITY ANY AUTO ALLON/NED SRC�st71EDULED HIUURTTEOODSSAUiOS AUTO WNED CO aBiNDtcci SINGLE LIMIT $ BODILY INJURY( Per parson) $ BODILY I NJUpoRV(Per accident$ Pare gent)AMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ AND WORKERS COMPENSASION AND EMPLOYERS' LIABILITY ANY CPREOPRIETORJPARTNERIEXECUTIVEV/❑N (M 15 to MEkR�� EXCLUDED? (�((b1 tltl ��yy ����dd D99sCRWIO PI&PERATIONS below N/A qq ttII ICU - I"ITS ER E.L.CIDENT $ -EA EMPLOYEE PGATE $ E-POLICY LIMIT $ A Technology Professional Liability MTK1565488A 3/13/2021 3/13/2022 $2.000,000 GREGATE $2,000,000 DEDUCTIBLE EACH CLAIM $0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (See attached AcoN 101 for addi9onal liability limits) Errors 8 Ommissians - The City of Santa Ana, officers, agent, employees and volunteers is an additional insured per BP 137 (02-09) The City of Santa Ana, officers, agents, employees and volunteers is an additional insured per BP 0448 01 06BPA1 06/09 Blanket Additonal Insured is pad of this policy. 11iN-llmiLgJ4Ji[/ City of Santa Ana, Officers, Agents, Employees and Volunteers Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The ACORD name and logo are registered marks of ACORD s 0 P"Mm aMeN tDn m I?FmEwm& APPROVBy. we R. V:lGWAI Risk Management Niatyst AGENCY CUSTOMER ID: 5576 �—n LOC r?n"° ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY INSURED TAPCO- KL (5576) HEALTHY OUTCOMES INC. 7897 E 24TH AVE DENVER, CO 80238 POLICY NUMBER MTK1565488A CARRIER NAIC CODE EFFECTIVE DATE: 3/13/2021 United States Liability Insurance Company 25895 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE COVERAGE PART LIMITS Businessowners Liability Liability and Medical Expenses $1,000,000 Medical Expense (per person) $10,000 Damages To Premises Rented To You (Any One Premises) $300,000 Hired and Non -owned Auto Each Occurrence Included Hired and Non -owned Auto Aggregate Included General Aggregate $2,000,000 Technology Professional Liability Each Claim Limit $2 000 000 Annual Aggregate Limit $2,000,000 Deductible $0 Intellectual Property Each Claim $1,000,000 Intellectual Property Aggregate $1,000,000 Privacy Breach Expense and Defense of Regulatory Claims Each Claim $1,000,000 Privacy Breach Expense and Defense of Regulatory Claims Aggregate $1,000,000 Retroactive Date 03/13/2020 ACORD 101 (2008/01) Copyright 2008 ACORD I The ACORD name and logo are registered marks of ACORD �I?i �,S 2, � ' ®1 RlekMwganmt Divieimt REVIEWED&IIM�rRCVMBr, F'Aa,G ram, vjt" AI - Ruk Management Analyst co a �IJ NOERWRITERS. INC. POLICY ENDORSEMENT Name of Assured Producer Healthy Outcomes Inc. 600165 7897 E 24TH AVE James Lundin Denver, CO 80238 700 E 9th Ave Suite 105 Denver, CO 80203 POLICY NUMBER: MTK1565488A ENDORSEMENT NUMBER: 015 COMPANY: United States Liability Insurance Company POLICY EFF. DATE: 03/13/2021 POLICY EXP. DATE: 03/1312022 ENDORSEMENT EFF. DATE: 11/04/2021 Endorsement 015 Company Issued Endorsement . ALL OTHER PROVISIONS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. This Endorsement is issued by TAPCO Underwriters, Inc. Post Office Box 286 Burlington, NC 27216 800-334-5579 Page 1 of 1 H 11 W e l 1015 w� Authorized Representative _ _ xlek nl�agm�n,tutwelon (REVIE DSpAPPROVED BY. ® Risk Nlanage.e.t Malyst ENDORSEMENT #15 This endorsement, issued by United States Liability Insurance Company to HEALTHY OUTCOMES INC. forms a part of Policy Number MTK1565488A effective on 11/4/2021 (MO. DAY YR.) at 12:01 A.M. Add/Remove/Amend Businessowners Additional Insured Endorsement In consideration of no change in premium it is hereby agreed that the following form(s) is(are) amended: BP-137 02/09 - Amendment Of Other Insurance Condition: Primary And Non -Contributory - Designated Person Or Organization BP0448 01/06 - Additional Insured - Designated Person Or Organization All other terms and conditions of this Policy remain unchanged. ADD —REM (03-01) RtskTi t; ment DMsm i, "_ Re EwED&APPRovED 8r. 4W ®' Risk Management Analyst POLICY NUMBER: MTK1565488A BUSINESSOWNERS BP 04 48 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) Or Organization(s): Effective Date: 11/04/2021 12:01 AM THE CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who is An Insured in Section II - Liability: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, 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 in the performance of your ongoing operations or in connection with your premises owned by or rented to you. BP 04 48 01 06 © ISO Properties, Inc., 2004 w.k�oM�� rRREVIEWED6 APPY �E�: R��O��V//®�B� LMWNW' r'1FhGi'�� P- VaiR/Vf(F4 Risk Management Anatyst UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA Thisendorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM AMENDMENT OF OTHER INSURANCE CONDITION: PRIMARY AND NON-CONTRIBUTORY - DESIGNATED PERSON OR ORGANIZATION Schedule Name of Person or Organization: Effective Date: 11/04/2021 12:01 AM THE CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 7897 E 24TH AVE DENVER, CO 80238 If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement SECTION III - COMMON POLICY CONDITIONS paragraph H. Other Insurance is amended by the addition of the following: This insurance is primary and non-contributory as respects our coverage for the person or organization named in the Schedule. We will not seek contribution from any other insurance policy available to the person or organization named in the Schedule for "bodily injury", "property damage" or "personal and advertising injury" covered under this policy. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another shown. RiskMaagematDMs1un rrnn R��EVIEWED&APPROVED B�Y(.' �! ® 2uk Management Analys[ BP 137 (02-09) tar!RWRITERS. INC. POLICY ENDORSEMENT Name of Assured Producer Healthy Outcomes Inc. 600165 7897 E 24TH AVE James Lundin Denver, CO 80238 700 E 9th Ave Suite 105 Denver, CO 80203 POLICY NUMBER: MTK1565488A ENDORSEMENT NUMBER: 019 COMPANY: United States Liability Insurance Company POLICY EFF. DATE: 03/13/2021 POLICY EXP. DATE: 03/13/2022 ENDORSEMENT EFF. DATE: 12/09/2021 Endorsement 019 Company Issued Endorsement . ALL OTHER PROVISIONS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED This Endorsement is issued by RMYI D-Y TAPCO Underwriters, Inc. Post Office Box 286 Burlington, NC 8001334-5579 2 2 6 II II I II I I I I I I II Authorized Representative Page 1 of 1 1019 itiale Management I)hvlon BY. ®iIF�I' //R�EVIEWED&{APPR��O��V//E�D rAF�F Z V.s44 = 1W Risk Management Malyst POLICY NUMBER: MTK1565488A BUSINESSOWNERS BP 04 97 01 06 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Person Or Organization: Effective Date: 12/09/2021 12:01 AM THE CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section III - Common Policy Conditions is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. Ri,1MwigematDMsian 4�� REVIEWEDnAPPROVED BY: Risk Manag,o nt Analyst BP 04 97 01 06 ISO Properties, Inc., 2004 XW Lr �..---� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/20/2021 THISCERTIFICATE IS ISSUED ASA MATTEROF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BYTHE 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 isan ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisionsor be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of thepollgO certain policies mayrequireanendorsement Astatementonthis certificatedoesnotconferrightstothecertificateholderinlieu ofsuchendorsement(s), PRODUCER CONTACT NAME- James Lundin LUNDIN JAMES(0713365) PHONE FAX 700 E 9TH AVE #105 (A/C, NO, E)T): 303-433-4542 (A/C, NO): 866-614-1373 E-MAIL DENVER CO 80203 ADDRESS- jlundin@farmersagent.com INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: Truck Insurance Exchange 21709 INSURERB: Farmers Insurance Exchange 21652 HEALTHY OUTCOMES, INC. 7897E 24TH AVE INSURERC: Mid Century Insurance Company 21687 INSURERD: Fire Insurance Exchange 21660 INSURERE: DENVER CO 80238-2451 INSURERF. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT W ITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE ADDTL INSD SUBR WVO POLICYNUMBER POLICY EFF (MM/DD/YYYY) POUCYEXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE F1 OCCUR DAMAGE TO RENTED PREMISES (Ea Occurrence) $ MED EXP (Any one person) $ PERSONAL& ADV INJURY $ GENT AGGREGATE UMITAPPLIES PER: GENERALAGGREGATE $ POLICY ❑ PROJECT ❑ LOC PRODUCTS-COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (Per accident) $ OWNEDAUTOS SCHEDULED ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOSONLY PROPERTY DAMAGE (Per accident) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILI Y X1 PER STATUTE OTHER $ E.L. EACH ACCIDENT $ 1,000,000 D ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVEOFFICER/MEMBER EXCLUDED? (Mandatory in NH) Y N/A Y 04176360 01/17/2022 01/17/2023 E.L. DISEASE -EA EMPLOYEE 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 Ifyes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ertificate holder is listed as Additional insured on the named Insured's general liability policy. aiver of Subrogation applies in favor of the certificate holder on the workers compensation policy. The consultant hereby grant to Grantee a waiver of any right o subrogation which any insurer of said consultant may aquire against City by virtue of the payment of any loss under such insurance. Consultant agrees to btain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a CERTIFICATE HOLDER CANCELLATION City of ants Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CA BE E PIRATION Risk Management Division DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOWMCEW E CYPROVISIONS. 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE James Lundi Santa Ana, CA 92702 Risk Managemenf Division a�\°x REVIEWED & APPROVED BY: 1, ACORD 25 (2016/03) 01988-2015 ACORD C , 31-1769 11-15 The ACORD name and logo are registered marks of ACORD Risk Management specialist Digitally signed by Ton Pierson Tori Pierson Dt, 2021011510:10:12-07'00 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/7/2022 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 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 TAPCO- KL (5576) PO Box 286 Burlington, NC 27216 CONTACT NAME PHONE (A/C No, Ext): FAX (A/C No): EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED HEALTHY OUTCOMES INC. 7897 E 24TH AVE DENVER, CO 80238 INSURER A: United States Liability Insurance Company 25895 INSUREB B: INSURER C: INSURER D: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY MTK1565488B 3/13/2022 3/13/2023 EACH OCCURENCE $1,000,000 ES ERENTED RMI a occurrence) $300,000 MED EXP (Any one person) $10,000 CLAIMS -MADE M OCCUR PERSONAL & ADV INJURY p` GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG X POLICY PRO LOC i El $ AUTOMOBILIE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO ATTQNED �SYODULED BODILY INJURY (Per accident) $ (eacdet�AMAGE Prrcin $ NON -OWNED HIRED AUTOS AO UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSASION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N QFFICER/MFMRn7 EXCLUDED? (Mandatory in ) N / A WC STgTU- OTH- TORY LIMITS I ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DrCRIPT(ON"FeOrPERATIONSbelow A Technology Professional Liability MTK1565488B 3/13/2022 [3/13/2023 EACH CLAIM $2,000,000 ANNUAL AGGREGATE $2,000,000 DEDUCTIBLE EACH CLAIM $0 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (See attached Acord 101 for additional liability limits) Technology Professional Package. The City of Santa Ana, officers, agents, employees and volunteers are named as additional insureds with respects to general liability. Includes a waiver of subrogation (waiver of transfer of rights of recovery against others to us). BP-134 06/09 Blanket Additional Insured is part of this policy. CERTIFICATE HOLDER CANCELLATION The City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Risk Management EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE Division POLICY PROVISIONS. 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE k' Santa Ana, CA 92702 IN) m & frzcr+rExr ACORD 25 (2010/05) Copyright 1988-2010 ACORD CO The ACORD name and logo are registered marks of ACORD rzisk Mar,agemmc ClericxlA de AGENCY CUSTOMER ID- 5576 i LOC #. All ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY INSURED TAPCO- KL (5576) HEALTHY OUTCOMES INC. 7897 E 24TH AVE POLICY NUMBER DENVER, CO 80238 MTK1565488B CARRIER NAIC CODE EFFECTIVE DATE: 3/13/2022 United States Liability Insurance Company 25895 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE COVERAGE PART LIMITS Businessowners Liability Liability and Medical Expenses $1,000,000 Medical Expense (per person) $10,000 Damages To Premises Rented To You (Any One Premises) $300,000 Hired and Non -owned Auto Each Occurrence Included Hired and Non -owned Auto Aggregate Included General Aggregate $2,000,000 Technology Professional Liability Each Claim Limit $2,000,000 Annual Aggregate Limit $2,000,000 Deductible $0 Intellectual Property Each Claim $1,000,000 Intellectual Property Aggregate $1,000,000 Privacy Breach Expense and Defense of Regulatory Claims Each Claim $1,000,000 Privacy Breach Expense and Defense of Regulatory Claims Aggregate $1,000,000 Retroactive Date 03/13/2020 REVORED &. APPROVED far. Risk Managenxent Clerical Ai de ACORD 101 (2008/01) Copyright 2008 ACORD Cumrumm i iurv. mii iiynib icscrvcu. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MTK1565488B BUSINESSDWNERS BP 04 48 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSDWNERS COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) Or Organization(s): Effective Date: 0311312022 THE CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who is An Insured in Section II - Liability: 3. Any person(s) or organizatlon(s) shown in the Schedule is also an additional insured, 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 in the performance of your ongoing operations or in connection with your premises owned by or rented to you. rel !iF��Ul . PRovE ENDORSEMENT #15 This endorsement, issued by United States Liability Insurance Company to HEALTHY OUTCOMES INC. forms a part of Policy Number MTK1565488A effective on 11/4/2021 (MO. DAY YR.) at 12:01 A.M. Add/Remove/Amend Businessowners Additional Insured Endorsement In consideration of no change in premium it is hereby agreed that the following form(s) is(are) amended: BP-137 02/09 - Amendment Of Other Insurance Condition: Primary And Non -Contributory - Designated Person Or Organization BP0448 01/06 - Additional Insured - Designated Person Or Organization All other terms and conditions of this Policy remain unchanged. ADD —REM (03-01) RA i o�i� &a��U IU ui E POLICY NUMBER: MTK1565488B BUSINESSOWNERS BP 04 97 01 06 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Person Or Organization: Effective Date: 03/13/2022 THE CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section III - Common Policy Conditions is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. rel !IF��UI . PRov Risk W�gen�t Ciffic_] BP 04 97 01 06 ISO Properties, Inc., 2004 i CERTIFICATE OF LIABILITY INSURANCE THISCERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOTCONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the polWies) 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 CONTACT NAME, James Lundin LUNDIN JAMES(0713365 PHONE FAX 700 E 9TH AVE #105 (A/C, NO, Oft 303-433-4542 866-614-1373 E-MAIL DENVER CO 80203 ADDRESS: jiundin@farmersagent.com INSURER(S) AFFORDING COVERAGE NAIC INSURED INSURERA. Truck Insurance Exchange 21709 INSURERS: Farmers Insurance Exchange 21652 HEALTHY OUTCOMES, INC. 7897 E 24TH AVE INSURERC:* Mid Century Insurance Company 21687 INSURER D: Fire Insurance Exchange 21660 DENVER CO 80238-2451 INSURERE: INSURERF. COVERAGES CERTIFICATE NUMBER* REVISION NUMBER: THIS ISTO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAME 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 SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I.TR TYPE OF INSURANCE ADOTL INSD SUBR Vivo POUCYNUMSER POLICY EFF (MM/DD/YYYY) POUCYEXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED P R E M I S E S (Ea Occurrence) $ MED EXP (Any one person) $ PFRSONAL&ADV INJURY . ......... $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY [—] PROJECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANYAUTO BODILY INJURY (Per person) $ OWNEDAUTOS SCHEDULED ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ HIREDAUTOS NON -OWNED ONLY AUTOSONLY -.-...--------......_...-.-_..-....-.----... $ UMBRELLA UABI OCCUR EACHOCCURRENCE ........ .. . . . $ EXCESSLIAR CLAIMS -MADE AGGREGATE $ DED [� RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABIUTY JfHER $ D ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EYK N/A Y A04176360 01/17/2022 01/17/2023 E.L. EACH ACCIDENT $ 1,000,000 E.L.DISEASE-EA P YEE 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 lfyes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPCRATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached ffmore space Is required) ,ertificate holder is listed as Additional insured on the named Insured's general liability policy. Nalver of Subrogation applies in favor of the certificate holder on the workers compensation policy. The consultant hereby grant to Grantee a waiver of any right -o subrogation which any Insurer of said consultant may squire against City by virtue of the payment of any loss under such Insurance. Consultant agrees to )btain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a AiMvPff_nf_qi ihffmatinn-AndarsArnAnt-fiTimAhaJnsa CERTIFICATE HOLDER Risk Management Division 20 Civic Center Plaza ACORD 25 (2016/03) 31-1769 11-15 =*W.WL*M SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCO AUTHORIZED REPRESENTATIVE James Lundl R.D & tUPROVED BY. 4, 1988-2015 ACORD C ftM_�ToToTqs7iTTiTj-7 Mis 577-71773,La t - .