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HomeMy WebLinkAboutMELGOZA, JORGE dba ARDENT ERGONOMICSINSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES CLERK OF COUNCIL Z FEB 0 3 2022 DATE: N-2022-027 AGREEMENT WITH JORGE MELGOZA, DBA ARDENT ERGONOMICS TO PROVIDE PREVENTATIVE ERGONOMICS ASSESSMENTS 0' NK�ww��f-I+a La..be-&) (am) THIS AGREEMENT is made and entered into this 23rd day of November 2021 by and between Jorge Melgoza, doing business as Ardent Ergonomics ("Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). City and Consultant may be collectively referred to as the "Parties" or individually as a "Party." RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of preventative ergonomic assessments. B. Consultant represents that it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional in the same field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the Parties agree as follows: 1. SCOPE OF SERVICES Consultant shall perform those services relating to preventative ergonomic assessments including but not limited to those services set forth in Exhibit A, attached hereto and incorporated herein by reference. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A. The total sum to be expended under this Agreement shall not exceed fifty thousand dollars and zero cents ($50,000) during the term of this Agreement. C. Payment by City shall be made within forty-five (45) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work that fails to meet the standards of performance set forth in the Recitals, which may reasonably be expected by City. Page 1 of 8 3. TERM This Agreement shall commence on the date first written above and continue for a three (3) year term until November 22, 2024, unless terminated earlier pursuant to Section 14, below. 4. INDEPENDENT CONSULTANT During the entire term of this Agreement, Consultant shall be construed to be an independent contractor and not an employee of the City, This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to its employees and shall be responsible for all applicable withholding taxes, 5. OWNERSHIP OP MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data that were provided to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk, 6. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Minimum Scope and Limit of Insurance Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this projoet/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. Page 2 of 8 2. Automobile Liability: ISO Form Number CA 00 01 covering any auto (Code 1), or if Consultant has no owned autos, hired, (Code 8) and non -owned autos (Code 9), with a limit no less than $1,000,000 per accident for bodily injury and property damage. 3. Workers' Compensation; as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. coverage and/or the higher limits maintained by the Consultant. Any available b. Other Insurance Provisions 1. Additional Insured Status: The City, 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 Consultant including materials, parts, or equipment furnished in connectionwith such work or operations. General liability coverage can be provided in the form of an endorsement to the Consultant's insurance (at least as broad as ISO Form CG 20 10 It 85 or if notavailable, 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). 2. Primary Coverage: For any claims related to this contract, the Consultant's insurance coverage shall be primary coverage at least as broad as ISO CO 20 01 04 13 as respects the City, its officers, officials, employees, and volunteers. Any insurance or self- insurance maintained by the City, its officers, officials, employees, or volunteers shall be excess of the Consultant's insurance and shall not contribute with it. 3. Notice of Cancellation: Each insurance policy required above shall provide that coverage shall not be canceled, except with notice to the City. 4. Waiver of Subrogation: Consultant hereby grants to City a waiver of any right to subrogation that any insurer of said Consultant may acquire against the City by virtue of the payment of any loss under such insurance. Consultant agrees to obtain 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 waiver of subrogation endorsement from the insurer. Page 3 of 8 Self -Insured Retentions: Self -insured retentions must be declared to and approved by the City. The City may require the Consultant 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 policy language shall provide, or be endorsed to provide, that the self -insured retention may be satisfied by either the named insured or City. 6. 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:VH, unless otherwise acceptable to the City. Verification of Coverage: Consultant shall furnish the City with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage requiredby this clause) and a copy of the Declarations and Endorsement Page of the COL policy listing allpolicy endorsements to City before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive the Consultant's obligation to provide them. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. 8. Subcontractors: Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Consultant shall ensure that City is an additional insured on insurance required from subcontractors. 9. Special Risks or Circumstances: City reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. INDEMNIFICATION Consultant agrees to and shall indemnify, defend, and hold harmless the City, its officers, agents, employees, consultants, counsel, and representatives from liability for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims: (1) for personal injury, including death, and claims for property damage, arising from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in Section t of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable Page 4 of 8 relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 8. RECORDS Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a. representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. 9. CONFIDENTIALITY If Consultant received from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either Party by any subsidiary and/or agent of the other Party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant and disclosed without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 10. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interest and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. Page 5 of 8 11. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by facsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Cleric of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, California 92702-1988 Facsimile (714) 647-6956 Copies to: Executive Director of Human Resources City of Santa Ana 20 Civic Center Plaza (M-24) P.O, Box 1988 Santa Ana, California 92702 Facsimile (714) 647-5311 To Consultant: Ardent Ergonomics Attn: Jorge Molgoza 6867 Golferest Drive, Ste. 51 San Diego, CA 92119 A Party may change its address by giving notice in writing to the other Party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by facsimile, communication shall be effective or deemed to have been given twenty-four (24) horns after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 12. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the Parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail and will serve to fully supersede existing Agreement. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The Parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms or conditions hereof, shall not bind or obligate Consultant nor the City. Each Party to Page 6 of 8 this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 13. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without die City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services, which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 14. TERMINATION This Agreement may be terminated by the City with thirty (30) days written notice of termination to the Consultant. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product(s) completed as of such date, and in such case, such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work, which fails to meet the standard of performance specified in the Recitals of this Agreement. 15. NON DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Consultant affirms that it is an equal opportunity employor and shall comply with all applicable federal, state and local laws and regulations. 16, JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. The Parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. Page 7 of 8 17. PROFESSIONAL LICENSES Throughout the term of this Agreement, Consultant shall maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United Sates, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. , 18. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. IN WITNESS WHEREOF, the Parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA DAISY GOMEZ KRISTINE RIDGE Clerk of the Council CityManager APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Br6ndon Salvatierra Deputy City Attorney FOR APPROVAL: on Motsick Executive Director Human Resources Agency CONSULTANT 4wne Melgoz�,�% r Page 8 of 8 ARDENT ERGONOMICS 6867 Golfcrest Drive, Ste. 51 San Diego, CA 92119 760-390-5553 November 8, 2021 To: Samantha M. Lambert, Risk Management Supervisor City of Santa Ana I Human Resources Department I Risk Management Division Ardent Ergonomics appreciates the opportunity of providing the following quote to the City of Santa Ana for completion of preventative ergonomics assessments. Scope of Services Ardent Ergonomics understands the scope of services and can comply with all components. We will: ❑ Systematically assess each current Job Description. ❑ Determine risk factors and make written recommendations to reduce these risk factors by conducting and providing. ❑On -site assessments and modifications ❑Employee education ❑Ergonomic equipment recommendations ❑Equipment Set Up/Training Approach to Project Ardent Ergonomics will: 0 Coordinate a time to meet with the City of Santa Ana HR/RM personnel Dept Manager/ Supervisor and employees ❑ Observe and each employee performing his or her job, take measurements of workstation including furniture and equipment used to perform job, provide written documentation of each assessment with adjustments and equipment recommendations. ❑ Discuss adjustments and equipment recommendations with HR/RM personnel Dept Manager/ Supervisor. ❑ Identify and discuss alternate and or modified job duties when possible. Fee rate is $110.00 hr. Professional time, $70.00 hr. Travel time and mileage is at current IRS rate. Comments: The above recommendations do not consider potential delays caused by business interruptions during the completion of assessments. Jorge Melgoza, CEAS, REAS Bilingual -Fluent Spanish Certified Ergonomic Assessment Specialist 760-390-5553 Digitally signed by Francine R. Francine R. Villareal _villareal ACC)R"® CERTIFICATE OF LIABILITY INSURANCE wt�d4 �' L� /20/2022 ouzo/zoz2 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 CONTACT LAZARO NETO NAME: StateFarm LAZARO NETO PHONE (619)-229-6799 FAX(MC. No EauIAIcNo,: (619)-229-6796 3924 EL CAJON BLVD. AIL ADDRESS, lazaro.neto.m36f@statefarm.com • ® INSURERS AFFORDING COVERAGE NAM # INSURER A: State Farm Fire and Casualty Company 25143 SAN DIEGO CA 92105 INSURED INSURER B : MELGOZA, JORGE B INSURER C: 6867 GOLFCREST DR APT 51 INSURER D: NSURER E SAN DIEGO CA 92119 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 LTR TYPE OF INSURANCE ADOLSUBR POLICY NUMBER POLICYEFF MMIDD/YYYY POLICYEXP MWOD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED REMISES Ea occurrence)$ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY S 1,000,000 A Y Y 90-E3-KB74-5 10/15/2021 10/15/2022 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT LOC GENERALAGGREGATE S 2,000,00o PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJ DRV(Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAR Id OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N I A STATUrE ER E.L. EACH ACCIDENT $ E.L. DISEASE EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The City, its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE / � SANTA ANA, CA 92702 .L--� WekManagnrlatDiviaim dti i REVIEWED&APPBOV®Br 01988-2015 ACORD C `I: o IN9pr�:% f�Anr.:.we ,, �lllcvAl ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ' Risk Managemem Analyst Policy No. 90 E3K874 0332—FAC7 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 E3K874 Named Insured: MELGOZA, JORGE B 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119 2444 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA ITS OFFICERS OFFICIALS EMPLOYEES & VOLUNTEERS 20 CIVIC CENTER PLZ SANTA ANA CA 92701 4058 1. SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage', or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED RiekMnugvnadDMs[= W,,/ Rt:va &APPROVED Sr. qfaecrr a t R. vj&4tc1 ® R6k Management Analyst 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit' brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the 'occur- rence" or offense took place; CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 1007033 148011 08-21-2014 m, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. RWk MnrwgemmtDMston Re EWER&A"Rovmev: �'•. Risk Management Malyst Policy No. 90 E3K874 5 0332—FAC7 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 E3K874 5 Named Insured: MELGOZA, JORGE B 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119 2444 Name And Address Of Person Or Organization: CITY OF SANTA ANA ITS OFFICERS OFFICIALS EMPLOYEES & VOLUNTEERS 20 CIVIC CENTER PLZ SANTA ANA CA 92701 4058 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under 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. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 O, Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Rl8rMWw9dn%dDMsIun g�y=R REVIEWED&p�AjPPPIR.OV/ DBr.. ' F�1l.s.tM1 h. V:l ®'. Risk Management Matys[ State Farm Mutual Automobile Insurance Company Auto Insurance Binder California Policy Number: 583 7885-D15.55 Agent Named Insured(s) Lazaro Neto JORGE B MELGOZA, ANNA MELGOZA 3924 El Cajon BLVD San Diego CA 92105 Mailing Address (619) 229-6799 6867 Golfcrest Or Apt 51 San Diego CA 92119-2444 Vehicle Year: 2012 Make: HONDA Model: ACCORD Body Style: "LX" 4D SED GAS Vehicle Identiflication Number: 1 HGCP2F32CA082366 COVERAGES AND LIMITS No coverage is provided for your lending institution or leasing company if Comprehensive and Collision coverages are not included on the policy. If you did not select those coverages, you may need to contact State Farm® to discuss adding those coverages to your policy. The premium shown on this binder must be in compliance with the Company's rules and rates and is subject to revision. The premium amounts do not include the additional fees required if the monthly payment plan was selected. Coverages Applied For Limits/Deductibles Six -Month Premium Liability -Bodily Injury Property Damage $11001 M1V$1 Mil $411.86 Comprehensive Deductible $500 $19.38 Collision Deductible $500 $131.81 Emergency Road Service Included $3.69 Uninsured Motor Vehicle -Bodily Injury $500,000/$1Mil $123.70 Uninsured Motor Vehicle -Property Damage Included $3.87 Total Six -Month Premium $694.31 PREMIUM ADJUSTMENTS California Good Driver Discount Driving Safety Record Discount Multiple Automobiles Discount Policy Number: 583 7885-D15-55 Page 1 of 3 Named Insured(s): JORGE B MELGOZA, ANNA MELGOZA Effective date: 10-15-2021, Application date/time:10-15-2021/06:22 PM CDT 10041e4 9CAA2(rev iorzan) RIAMucgemeitDivi9nn [{ RavlaW &APPR�O�V�EDBr,/r ®'. ® Risk management Analyst (& StateFarm° Multiple Line (Renters) Discount ADDITIONAL INFORMATION During the past 10 years has any driver or household member had License suspended, revoked, or refused? No Does any driver have In the last 10 years, a conviction for driving under the influence of alcohol or drugs, or a conviction for vehicular manslaughter while under the influence of alcohol or drugs? No An at -fault accident within the last 6 years? No A minor conviction within the last 6 years? No Primary use of vehicle? Business TERMS AND CONDITIONS State Farm Mutual Automobile Insurance Company of Bloomington, Illinois, hereby binds coverage for the insurance applied for as of the requested effective date for a period of 60 days from such date, subject to all the terms and conditions of the applicable policy and endorsements in current use by such Company. Coverage under this binder will terminate (1) when the Declarations Page of a policy is issued to you or (2) when canceled in accordance with law. By submission of this application, you agree that: (1) you have read this application, (2) your statements on this application are correct, (3) statements made on any other applications on this date for automobile insurance with this company are correct and are made part of this application, (4) you are the sole owner of the described vehicle(s) except as otherwise stated, and (5) the limits and coverages were selected by you. It is further understood and agreed that no insurance is effective under this agreement (a) unless the binder is completed designating the company accepting this application or (b) until the date the policy or binder is issued by the company accepting this application. Consumer reports may be ordered in conjunction with this application. These reports provide information that assists with determining your eligibility for insurance and the price you are charged. State Farm considers the representations you have made about the licensing and driving record(s) to be material. Any concealment or misrepresentation - whether fraudulent, intentional, or unintentional - about your driving record could result in State Farm's re -rating, cancellation, or rescission of your car insurance policy. A rescission could result in your car policy being void from its inception, as if no car policy ever existed. Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your authorization as permitted by law. If you would like additional information about the collection and disclosure of personal information, please contact your State Farm agent. You may also act upon your right to see and correct any personal information in your State Farm files by writing your State Farm agent to request this access. Evidence of a valid U.S. or Canadian license for all drivers in your household must be provided to State Farm within 12 months in order to continue coverage. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY Policy Number: 583 7885-01555 Named Insured(s): JORGE B MELGOZA, ANNA MELGOZA Effective date: 10-15-2021, Application dateltime:10-15-2021/06:22 PM CDT 1 WOU le CA, 12 (rev 10=17) Page 2 of 3 laslr Mmagemmt 1xWelwt lihmemm & APPRovac Or .11, �1, FM� R. VXA44 i Risk Management Analyst AStateFarm- DRIVING SAFETY RECORD RATING PLAN Your driving safety record, along with other rating factors, determines what you pay for liability, medical payments, comprehensive, collision, and uninsured motor vehicle coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. If the policy is assigned to Rate Level 2 or higher, has been at the same level for 12 months, and has no chargeable accidents or convictions that have not been previously considered, the Rate Level is reduced by 1 level. The Rate Level is increased if there are subsequent chargeable accidents or convictions. A policy may qualify for our best (superior) rate level if all drivers assigned to the policy have had no chargeable accidents or convictions in the last 6 years. DEFINITION OF CHARGEABLE ACCIDENTS - Chargeable accidents for new business are those which resulted in death, or damage to any property in the amount of more than $1,000*. Chargeable accidents for renewal business are those for which State Farm paid more than $1,000* under the Property Damage Liability and Collision Coverages combined. *$750 or more if the accident occurred prior to December 11, 2011. For more information about the rating plan, please contact your State Farm agent. IMPORTANT NOTICE: THE MINIMUM AUTO LIABILITY COVERAGE LIMITS REQUIRED UNDER CALIFORNIA LAW ARE $15,000 PER PERSONI$30,000 PER ACCIDENT FOR BODILY INJURY AND $5,000 FOR PROPERTY DAMAGE. WE ARE LEGALLY REQUIRED TO FURNISH THESE LIMITS AND WILL, IF REQUESTED. Policy Number: 583 7885-D15-55 Named Insured(s): JORGE B MELGOZA, ANNA MELGOZA Effective date: 10-15-2021, Application dateltime:10-15-2021106:22 PM CDT 1R041N Ie CA.12 (m 10201]) Page 3 of 3 1tIAMn Wg dDlAsIml RenEwEo&Arw4ovm Bv: ® Risk Management Malyst Ct7Y of SA aTA AkA RISK MA ACDAEh'T < &.ems nF HJefai. azso'-Rms Mart S" M* aorWn iamkire Charge Affidavit of Exemption for Workers' Compensation Insurance Jorge Melgota, president (Nome/rule) following declaration: F7�4-J hereby affirm under penalty of perjury, the I certify on behalf of Ardent Ergonomics that during the term (Consultont/Cornpan7 NeTei of my contract for preventative ergonomic assessment Services With the City of Santa Ana, (Type of service provided) I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: - Alle-0oze- Print Title: Qf�steAn Signature: Telephone: &e - WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. IARisk Mgmt\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance Ride Managanmt Division REVIEWED6 APPROVED BY: Fk� Z V:,U.cnrdE.' ® Risk Management Mzlyrt NOTICE OF COMPLIANCE CITY I„„ . "A ,AFF. II111RINTI'Ill I111"i I1111AGE ,CLE INC'LLEE CI I T'Ill1 , GREE OIEL I" O 1111E CLERK CIF 1111E C OLLC'I➢L Contractor Jorge B Melgoza Name: Project N-2022-027 Number: Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To Name: Provide Preventative Ergonomics Assessments The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: TYPE OF INSURANCE POLICY EXPIRATION COI DATE FILE NAME NUMBER DATE Jorge B Melgoza dba Ardent AUTOMOBILE LIABILITY 5837885DI555 10/15/2022 09/20/2022 Ergonomics COI Exp 10-15-22 RMD02012022.pdf Jorge B Melgoza dba Ardent GENERAL LIABILITY 90E3K8745 10/15/2022 01/20/2022 Ergonomics COI Exp 10-15-22 RMD02012022.pdf Jorge B Melgoza dba Ardent WORKERS COMPENSATION AND WAIVER 01/17/2023 09/20/2022 Ergonomics COI EMPLOYERS' LIABILITY Exp 10-15-22 RMD02012022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 9/20/2022 12:36 PM NOTICE OF COMPLIANCE Contractor Jorge B Melgoza Name: Project N-2022-027 Number: Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To Name: Provide Preventative Ergonomics Assessments The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE AUTOMOBILE LIABILITY 5837885DI555 04/15/2023 .........., 09/30/2022 . ........................ Melgoza.pdf GENERAL LIABILITY 90E3K8745 10/15/2023 10/10/2022 BUS CERT 2022 MELGOZA.pdf Jorge B Melgoza dba Ardent WORKERS COMPENSATION AND WAIVER 01/17/2023 09/20/2022 Ergonomics COI EMPLOYERS' LIABILITY Exp 10-15-22 RMD02012022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team NOTICE OF COMPLIANCE CITY . "A ,AM I1111RI T I'III I IPi 1111AGE ,CND INCLUDE Ck I 111 1AGREEMENTTOT111IE CLERK CSC 111I➢C COUNCIL Contractor Jorge B Melgoza Name: Project N-2022-027 Number: Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To Name: Provide Preventative Ergonomics Assessments The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: TYPE OF INSURANCE POLICY EXPIRATION COI DATE FILE NAME NUMBER DATE AUTOMOBILE LIABILITY 5837885DI555 : 04/15/2023 09/30/2022 Melgoza.pdf BUS CERT GENERAL LIABILITY 90E3K8745 10/15/2023 10/10/2022 2022 MELGOZA.pdf Affidavit of Exemption for WORKERS COMPENSATION AND WAIVER 01/03/2024 01/05/2023 Workers EMPLOYERS' LIABILITY Compensation Insurance .............. .............. 202 Lpdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/9/2023 5:17 PM NOTICE OF COMPLIANCE CITY . "A ,AM I1111RI T I'III I IPi 1111AGE ,CCp INCLUDE Ck I 111 1AGREEMENTTOT111IE CLERK CSC 111I➢C COUNCIL Contractor Jorge B Melgoza Name: Project N-2022-027 Number: Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To Name: Provide Preventative Ergonomics Assessments The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE NUMBER DATE COI DATE FILE NAME AUTOMOBILE LIABILITY 5837885DI555 10/15/2023 04/03/2023 Jorge col - santa ana.pdf BUS CERT GENERAL LIABILITY 90E3K8745 10/15/2023 10/10/2022 2022 MELGOZA.pdf Affidavit of Exemption for WORKERS COMPENSATION AND WAIVER 01/03/2024 01/05/2023 Workers EMPLOYERS' LIABILITY Compensation Insurance .............. .............. 202 Lpdf. Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 4/5/2023 2:27 PM NOTICE OF COMPLIANCE CITY "A',1CC. I1111RINT I'III I III°i II11AG➢E AND INCLUDE CE I 11111 AGR E➢E k1➢EN I TO 1111I E CLERIC CSC 1111I E COUNCIL L Contractor Jorge B Melgoza Name: Project N-2022-027 Number: Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To Provide Name: Preventative Ergonomics Assessments The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: EXPIRATION TYPE OF INSURANCE POLICY NUMBER COI DATE FILE NAME DATE BUS CERT CITY AUTOMOBILE LIABILITY 5837885D1555 04/15/2024 10/02/2023 OF SANTA ANA 2023.pdf GENERAL LIABILITY 90E3K8745 10/15/2024 10/02/2023 jorge.pdf Affidavit of Exemption for WORKERS COMPENSATION AND EMPLOYERS' WAIVER 01/03/2024 01/05/2023 Workers LIABILITY Compensation Insurance 2021.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 10/25/2023 1:03 PM �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/25/2024 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 CONTACT LAZARO NETO NAME: StateFarm LAZARO NETO PH/NE AI ;No • 61 g) 29- Ex 99 FAX No : (619)-229-6796 3924 EL CAJON ..o n je2NSURER ao F'E I 6 S AFFOR NG COVERAGE NAIC # INF 1,'E a r I lJ4Cn@Ve025151 SAN DIEGO 105 INSURED Ir ;URL, B : tate Farm 11futual Automobile Insurance Company 25178 MELGOZA, JORGE B ,JSURE ate- 6867 GOLFCREST D T 55ce URER D : Q • r, 071001 veOUREnf). INSURER : • • SAN DIEGO CA 9211s 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR TE PREMISES (E. oDAMAGE TO lccur ence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A Y Y 90-E3-K874-5 10/15/2023 10/15/2024 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 %< POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY 583 7885-D15-55A 04/15/2024 10/15/2024 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 1,000,000 ANY AUTO BODILY INJURY (Per accident) $ 1,000,000 A OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE Per accident $ 1,000,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana , its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF N(-)TlrF= WII I RF nF1 IVFRFn IN City of Santa Ana ACCORDANCE WITH THE POLICY PR( Risk Managlrmeftf Division 20 Civic Center Plaza i% REVIEWED&APPROVIDBY. AUTHORIZED REPRESENTATIVE 3; A4v Acevedo Santa Ana CA 92702 / ���� %t �• Risk Management Specialist © 1988-2015 ACORD ACORD 25 (2016/03) The ACORD name and logo are regis red marks of ACORD 1001486 132849.12 03-16-2016 Statefarm STATE FARM GENERAL INSURANCE COMPANY ❑ A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON,ILLINOIS ' RENEWAL_ DECLARATIONS p Bloomington IL 61702-2915 Policy Number 90-E3-K8 Addl insured -Section II Only Policy Period Effective D � Expiration oats OCT AT2 M-12-2CC1-FB86 F U 000913 3125 12 Months 15 21� OCT 15 2025 CITY OF SANTA ANA The poli y period begins and en 12:01 am standard time atf�ie premises location. ITS OFFICERS, OFFICIALS, =M EMPLOYEES & VOLUNTEERS ' 20 CIVIC CENTER PLZ Named Insured t-; Q SANTA ANA CA 9270I-4058 MELGOZA, JORGE B � Y. g'�'IIII+IIIIiiiLllilll+IIIIIIII'IIII'l"II'I"I'II'IIIII'IIIII'I " 0 4 O O Medical Office Policy " Automatic Renewal - If the policy period is shown as 12 months , this policy will be renewed automatically subjectto the premiums, rules and forms in effectfor each sllccLeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance with the policy, provisions or as required by law. Entity: Individual NOTICE: Information concerning changes in your policy language is included. Please call your agent if you have any questions. POLICY PREMIUM Discounts Applied: Renewal Year Sprinkler Claim Record $ 454.00 Prepared AUG 02 2024 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., smith its permission. 006408 294 Al Continued on Reverse Side of Page N Page 1 of 7 SQtisag nc,qi_, , +77a= RENEWAL DECLARATIONS (CONTINUED) Medical Office Policy for CITY OF SANTA ANA Policy Number 90-E3-K874-5 SECTION I - PROPERTY SCHEDULE Location Location of Limit of Insurance* Limit of Insurance* Seasonal Number Described Increase - Premises Coverage A - Coverage B - Business Buildings Business Personal Personal Property Property. 001 6867 GOLFCREST DR APT 51 No Coverage $ 2,600 25% SAN DIEGO CA 92119-2444 r As of the effective date of this policy, the Limit of Insurance as shown includes any increase in the limit due to'Inflation Coverage. SECTION I - INFLATION COVERAGE INDEX(ES) _ _ - Cov A - inflation Coverage Index: NIA Cov B - Consumer Price Index: 314.2 SECTION I - DEDUCTIBLES Basic Deductible $1,000 Special Deductibles: Money and Securities $250 Employee Dishonesty $250 Equipment Breakdown $1,000 Other deductibles may apply - refer to policy. Prepared AUG 02 2024 O Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 006408 Continued on Next Page Page 2 of 7