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HomeMy WebLinkAboutSALVATION ARMY, THE (8)Ord\ INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES V0 . U1. 7y T MAYOR CLERK OF COUNCIL Vicente Sarmienio DATE: MAYOR PRO TEM David Penaloza COUNCILMEMBERS Phil Bacerra Johnalhan Ryan Hernandez Jessie Lopez Nelida Mendoza Thai Viet Phan 0" C" U4Uy)3Ybwh) ( I) T-r The Salvation Army 10200 Pioneer Road Tustin, CA 92752 CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY 20 Civic Center Plaza . P.O. Box 1988 Santa Ana, California 92702 w.rw.sanla-ana-om November 1. 2021 Re: Extension of Agreement #A-2021-021-05 Dear Capt. J. Koebel: A-2021-021-05A CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Section I.B. (''Term of Agreement") or Agreement No. A-2021-021-05 ("Agreement"), entered into by the Salvation Army and the City of Santa Ana dated March 1, 2021, the parties hereby agree to extend the Term of the Agreement for a six (6) month period through February 28, 2022. The insurance certificates are required to be extended and/or renewed to cover this extension. All other lernis and conditions of said Agreement remain unchanged and in full force and effect. Sincerely, Steven Mendoza Executive Director, Conununity Development Agency CITY OF SANTA ANA: Kristine Ridne City Manager APPROVED AS TO FORRI: Son' ary Iho Ci r t Iney Ryan . I -I i+ e Assist n City . ttorney 'RNIY' oebel . ptain Division Secretary for l3usiuess SANTA ANA CITY COUNCIL I e`o.ne a. .e Saee oe aenab:a R_o�Yw, Pcac Je5,I wce: Nm Sa:ena Jomaman N,"Her�Jrr9et Ne4oa L�enO:n 1-I'm W,1 N. U, Warpt V::rrJr 11.S43 4x. vtyJ: Ye'drJ6 F Jl_nIJ-ri. nl riot .�3 i.3a d 1 t mlr-fF)�dC PiSirtldJnC onl r3asa, L dnd.�tNSddr=l arya�'1 r.p5 Francine Ggllel"sN"'by Fraadae R. Villa I Dale zo31.102 age 1 of 2 R. Villareal ��_:_. A� o> CERTIFICATE OF LIABILITY INSURANCE ATE (NEI D09/29/2021 09/29/2021 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 endorsement(s). PRODUCER Willis Towers Watson Insurance Services West, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT Willis Towers Watson Certificate Center NAME: PHONE aC No: 1-888-467-2378 ce1-877-945-7378 E-MAIL xti£icates@williS.com ADDRESS: INSURERS AFFORDING COVERAGE NAICY Nashville, IN 372305191 USA INSURER A: Westchester Surplus Lines Insurance Compan 10172 INSURED The Salvation Army - Division 17 30840 Hawthorne Blvd., Bldg D INSURER B: Greenwich Insurance Company 22322 INSURERC: EL Specialty Insurance Company 37885 INSURERD: Rancho Palos Verdes, CA 90275 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: W22306682 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 POLICY NUMBER POLICY EFF MMIDD POLICY EXP MIMIDDJYYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea owunence $ 1,000,000 X MED EXP(Any one person) $ 0 A Self Insured Retention: X $1,000,000 y G7183119A 002 10/01/2021 10/01/2022 PERSONAL &ADV INJURY $ 2,000,000 AGGREGATE LIMIT APPLI ES PER: GENERALAGGREGATE $ 4,000,000 GEN'L POLICY JE� X LOC PRODUCTS-COMPIOPAGG$ 4,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY YIN STATUTE ER E.L. EACH ACCIDENT $ ANYPROPRIETORIPARTNERIEX OFFICERIMEM EREXCLU ED7ECUTIVE ❑ NIA E.L. DISEASE -EA EMPLOYEE $ - (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ B Excess Auto Liability - CA y RAE500D21B11 10/01/2021 10/01/2022 Any Auto / CSL $3,000,000 Bel£-lnsd Retention $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Location Code: 17-145-10-01-01 - Santa Ana Hospitality House Shelter CA -Business Auto is fully Self -Insured per the attached State Certificate. SEE ATTACHED CERTIFICATE HOLDER City of Santa Ana Risk Management Division 20 Civic Center Pl... Santa Ana, CA 92702 ACORD 25 (2016I03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. _ AUTHORIZED REPRESENTATIVE REj ( �ENl' Y The ACORD name and logo are registered marks of ACORD SR ID: 21630631 —a -: 2252947 „se 7 Rink ManagmmntDivisian REvieVED &APPR.,IM4 . �OVD BYe. f.1�Q 4MN rRpp,, a , C ®' Ruk Management Analyst AGENCY CUSTOMER ID: LOC #: ,a OMY ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Insurance Services West, Inc. The salvation Army - Division 17 30840 Hawthorne Blvd., Bldg D Rancho Palos Verdes, CA 90275 POLICY NUMBER See Page 1 CARRIER - NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance FOR USE OF EMERGENCY SOLUTIONS GRANT CORONAVIRUS (ESG-CV) FUNDS. TERM: From: June 15, 2021 through December 31, 2021 The City of Santa Ana, its officers, officials, employees, and volunteers are included as an Additional Insured as respects to General Liability and Auto Liability as required by written contract or agreement. General Liability policy shall be Primary and Non -Contributory with any other insurance in force for or which may be purchased by Additional Insureds as required by written contract or agreement. Waiver of Subrogation applies in favor of Additional Insureds with respects to Workers Compensation, as permitted by law. INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 POLICY NUMBER: RWES00047506 EFF DATE: 10/01/2021 EXP DATE: 10/01/2022 SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Excess Workers Compensation E.L. Each Accident $1,000,000 CA EL Each Employee $1,000,000 Retention: $1,000,000 ADDITIONAL REMARKS: Excess Workers Compensation Policy No. RWEB00047506 provides coverage in the state of CA CA -Workers Compensation is fully Self -Insured per the attached State Certificate ACORD 101 (2008101) © 2108 ACORD C The ACORD name and logo are registered marks of ACORD SR ID: 21630631 BATCH: 2252947 CERT: W22306682 Risk ManagonWntDlvlelon Y Y REVIEWED&.pAP`P'ROVEDBY: tpimp '14rf+CrN�Q [tuk Management Analy5t S)ARW4U �WpA . W Y%pn9e[tEs A Public Service Agency This is to certify that: CERTIFICATE OF SELF-INSURANCE The Salvation Army NAME OF SELFINSURER 30840 Hawthorne Boulevard, Rancho Palos Verde, California 90275 ADDRESS, CITY, STATE, ZIP has been approved as a Self -Insurer under the California Compulsory Financial Responsibility Law and assigned Self -Insurance #k 202 pursuant to Section 16063 of the California Vehicle Code for the period August 1.9, 2021 through August 18, 2022 ruh�_Aj Q_' MANA ER Financial Responsibility Unit Department of Motor Vehicles 6R27(REU, IaM9)DH H7 RiskManagowd SWIM REmEWEo & APPRovao BY: --� Risk Management Analyst STATE OF CALIFORNIA Edmund G. Brown Jr., Governor DEPARTMENT OF INDUSTRIAL RELATIONS OFFICE OF SELF-INSURANCE PLANS 11050 Olson Drive, Suite 230 Rancho Cordova,CA 95670 Phone No. (916) 464-7000 FAX (916) 464-7007 CERTIFICATION OF SELF-INSURANCE OF WORKERS' COMPENSATION TO WHOM IT MAY CONCERN: 6*0 This certifies that Certificate of Consent to Self -Insure No. 0566 was issued by the Director of Industrial Relations to: The Salvation Army under the provisions of Section 3700, Labor Code of California with an effective date of November 15, 1933. The certificate is currently in full force and effective. Dated at Sacramento, California This day the 20th of April 2017 V Lyn Asio Booz, Chief ORIG: Craig Nicles Director Of Claims Management The Salvation Army 180 East Ocean Boulevard, 10th Floor Long Beach, Ca 90802 WnkMMV&ffl ntDivistmt REVIEWED&APPROVED BY: �---� Ruk Management Analyst Of POLICY NUMBER: G7183119A 002 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations As required by written contract signed by both parties prior to loss. Information required to complete this Schedule, if not shown above, will be shown In the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This Insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement applicable Limits Declarations. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 shall not increase the of Insurance shown in the IBele Management DlWalm REVIEWED & APPROVED BY: MWRisk Management Analyst NON-CONTRIBUTORY OTHER INSURANCE ENDORSEMENT Named Insured The Salvation Army Endorsement Number Policy Symbol Policy Number Policy Period Effective Date of Endorsement GLW G7183119A 002 10/01/2021 To 10/01/2022 10/01/2021 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Paragraph 4. c. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is deleted in its entirety and replaced by the following: c. Method of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method unless you are required by written contract to provide insurance that is primary and non-contributory, and the contract has been signed by you prior to any loss. Where required by such a written contract, this insurance will be primary and non-contributory only when and to the extent required by that written contract. However, under the contributory approach each insurer contributes equal amounts until It has paid its applicable limit of insurance or none of the loss remains, whichever comes first If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. All other terms and conditions remain unchanged. GLE0095 (07/10) ©Chubb. 2016. All rights reserved. Rink Manspe neM Divislon 3� a a REVIEWED&{yAPtPtR�.O�V/ID BY.' III Risk Management Analyst