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HomeMy WebLinkAboutVIETNAMESE LANGUAGE ACCESS/ASSISTANCE (VIETLA)INSURANCE ON FILE N-2023-140 WORK MAY PROCEED UNTIL INSURANCE EXPIRES q • Z� • 202'� CITY CLERK DATE: VA June 2023 Vietnamese Language Access/Assistance (VietLA) ("Interpreter") 0 2321 41h Street, Ste. C508 Santa Ana, CA 92705 Re: Eneaeement Agreement This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: 1. Event Description: VietLA will provide: (1) interpretation services, as further detailed in Exhibit A. The performances will take place at a City event, Vietnamese Business Forum, at times to be coordinated with event staff. 2. Date(s): Thursday, July 13, 2023, or at another date to be determined at the discretion of the City. 3. Event Time(s): 9:00 a.m. — 11:00 a.m., or at another time to be determined at the discretion of the City. 4. Location ("Property"): DoubleTree Hotel, 201 E. MacArthur Boulevard, Santa Ana, CA 92707 5. Compensation: Total amount not to exceed $450 under this Agreement (payable within forty-five (45) days following receipt of invoice pursuant to City accounting procedures); Interpreter must provide IRS form W-9 before payment can be made. Interpreter is responsible for direct payment to individual performers, if used. 6. Provided by City: advertising the program, space for the patrons attending, stage, sound and lighting equipment, and staff to assist with setup if needed for interpretation services. 7. Provided by Interpreter: insurance as required by the City and further detailed in Exhibit B, and all other equipment and materials necessary. 8. City Contact Person (for coordinating purposes only): Savannah Spicer 9. Independent Contractor: Interpreter shall, during the entire term of this Agreement, 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 Interpreter performs the services that are the subject matter of this Agreement; however, the services to be provided by Interpreter shall be provided in a manner consistent with all applicable standards and regulations. Interpreter shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 10. Indemnification: Interpreter, his or her agents, or employees (if applicable) agrees to and shall indemnify, defend, and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from and against all loss, expenses, or liability (including costs and attorney's fees) arising from the negligence or willful misconduct of Interpreter, his or her agents, or employees. N-2023-140 Pi -! 12 Letter Agreement— Vietnamese Language Access/Assistance "VietLA" 11. Release: Interpreter accepts the Property and any City -provided equipment used in connection with the performance in their "as -is" condition, with all faults. Interpreter fully releases, waives and discharges forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not to sue, City, its elected officials, officers, employees, agents and volunteers, and all persons acting on behalf of, by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event relating to the condition of the Property or City -provided equipment or Interpreter's use thereof. 12. The City shall have the right and royalty -free license to simulcast or produce and show a tape -delayed broadcast of Interpreter's presentation to the City community or general public, through webcast or any other means. This license shall be non-exclusive and the copyright shall remain with the Interpreter. Copies of Interpreter's presentation may be maintained by the City, and Interpreter consents to use of such recordings. 13. Interpreter is solely responsible for payment of royalty fees, performance fees, or similar fees that may be required by unions or similar organizations. Interpreter shall indemnify the City against any liability or damages, including attorney's fees, that may arise as a result of violation by Interpreter of copyright laws. 14. Interpreter shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection with any activities related to this Agreement. 15. This Agreement shall in all respects shall be interpreted, enforced, and governed exclusively by and under the laws of the state of California. Both parties 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. 16. This Agreement represents the complete and exclusive statement between the City and Interpreter regarding the subject matter herein and supersedes any and all other agreements, oral or written, between the parties. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Interpreter. CITY OF SA7AANA -Z=� 4or KRISTINE RIDGE City Manager ATTEST: enmfer L. Hall Ili City Clerk RECOMMENDED F RAPPROVAL Michael L. Garcia Executive Director Community Development Agency INTERPRETER ar z Nguyen Vietnamese Language Access/Assistance (VietLA) APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By 7 "`G1�4 k u Andrea Garcia -Miller Assistant City Attorney EXHIBIT A STATEMENT OF SERVICES City of Santa Ana - Community Development 20 Civic Center Plaza Santa Ana, CA 92701 ATTN: Savannah Spicer INTERPRETATION SERVICES: Thursday. July 13, 2023 8:00 am - 11:00 am VIETLA.ORG O+1 (650) 808-5121 $450.00 SUB TOTAL R/IETL Invoice INVOICE NO. 0523-022 DATE: 05/31/23 $450.00 $ 450.00 Bank: CHASE Account Name: VIETNAMESE LANGUAGE ACCESS/ASSISTANCE Account Number: 863 738 388 Routing Number: 322 271 627 Okarduz@vieda.crg O02321 4th SL Ste CS08 s Exhibit — Insurance Requirements Speaker/Performer shall procure and maintain, for the duration of the contract, insurance against claims for injuries to persons or damages to property that may arise from or in connection with products, materials, and/or services supplied to the City. The cost of such insurance shall be borne by the Speaker/Performer. Minimum Scope and Limit of Insurance: a. 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. 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 project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Automobile Liability: ISO Form Number CA 00 01 covering any auto (Code 1), or if Speaker/Performer has no owned autos, hired, (Code 8) and non -owned autos (Code 9), with 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. 4. Broader Coverage. If the Speaker/Performer maintains broader coverage and/or higher limits than the minimums shown above, the City requires and shall be entitled to the broader coverage and/or higher limits maintained by the Speaker/Performer. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. b. Self -Insured Retentions. Self -insured retentions must be declared to and approved by the City. The City may require the Speaker/Performer 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. c. Other Insurance Provisions: The insurance policies are to contain, or be endorsed to contain, the following provisions: 1. 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 Speaker/Performer including materials, parts or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Speaker/Performer's insurance (at least as broad as ISO Form CG 20 10 11 85 or both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; and CG 20 37 forms if later revisions used). Primary Coverage. For any claims related to this contract, the Speaker/Performer's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 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 Speaker/Performer'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. Speaker/Performer hereby grants to City a waiver of any right to subrogation that any insurer of said Speaker/Performer may acquire against the City by virtue of the payment of any loss under such insurance. Speaker/Performer 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. 5. Acceptability of Insurers. hisurance 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 City. 6. Verification of Coverage. Speaker/Performer 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 CGL policy listing all policy endorsements to City before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive the Speaker/Performer'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. Special Risks or Circumstances. City reserves the tight to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. Digitally signed ® '`�� CERTIFICATE OF LIABILITY I 090CE] DATE (MMIDDIYYYY) ��Ar'eswQngTYig �R��j06/01/2073 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS �PDISL �AiPOR9eFL�B"f BE CI HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALT BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE !S;UING IN§;QW.gt9i),WWRIZED 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 Arc 23 Insurance Services 24000 Alicia Parkway #17332 Mission Viejo CA 9269t CONTACT NAME: Aaron Rosen ONE aD No Est: (949) 484-7500 IN" No): ADDRESS: aaron@uc23insurance.com INSURERIS) AFFORDING COVERAGE NAIC# INSURER A: Stillwater Insurance Svcs, Inc 25180 INSURED VIETNAMESE LANGUAGE ACCESS/AS 1056 CABRILLO PARK DR SANTA ANA CA 92701 INSURER B : INSURER C: INSURER D: INSURER E 1 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. INSK LTR TYPE OF INSURANCE INSO WVO POLICY NUMBER (M,R"RYYYy) MMIDO/YYYY LIMITS x COMMERCIAL GENERAL LIABILITY RRENCE S 1,000,000 CLAIMS -MADE ERIOCCUR a occurrence) 9 IOQ000 y one person) $ IQ000 ADV INJURY MGA S 1,000,000 A Y Y BP2002951 09/28/2022 09/28/2023 GENT AGGREGATE LIMIT APPLIES PER'. GREGATE $ 2.000.000 POLICY �JECT �LOU COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY Ed) $ BODILY I NJ URY(Per person) S 1,000,000 ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS Y Y Bp2002952 09/28/2022 09/28/2023 BODILY INJURY(Peraccidenp S 2,000,000 HIRED V NON -OWNED AUTOS ONLY /� AUTOS ONLY r� (Per accident $ 1,000,000 S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE $ ICED I I RETENTION$ $ ORKERS COMPENSATION EMPLOYERS' LIABILITY Y/N - 1PERND STATUTE ER E.L. EACH ACCIDENT $ NY PROPRIE OR/PARTNERIEXECUTIVE OFFICEWMEMBER EXCLUDED? ElN I A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) I,, descdbe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana. its officers, officials, employees and volunteers must be covered as additional insureds on the CGL policy with respect to liability arising on[ of work or operations performed by or on behalf ofthe contractor including materials, parts or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the vendor/contractor insurance. City of Santa Ana is named as additional insureds per form SB 04 36 01 17 or equivalent. City of Santa Ana Risk Management Division 20 Civic Center 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. AUTHORIZED Avraw Ro-yev ©1988.2015 ACOR ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Risk Maugement Division .19 �° REVIEWEOSAPPROV®BY: ,, A*f, AdwuCd '. ® Risk Llanagement spe,JAW STILLWATER INSURANCE COMPANY AMENDED Modified Additional Interest Stillwater Insurance Group PO BOX 45126 JACKSONVILLE FL 32232-5126 855-712-4114 CHANGE EFFECTIVE 02/08/2023 BUSINESS OWNER POLICY DECLARATIONS Named Insured and Mailing Address Policy Number BP2002952 VIETNAMESE LANGUAGE ACCESS/ASSISTANCE (VIETLA) Agency —and Service Contact 1056 CABRILLO PARK DR #B SANTA ANA CA 92701-4439 ARC 23 INSURANCE SERVICES (949)484-7500 Policy Period 09/28/2022 to 09/28/202312:01AM Standard Time at the Premises location ** THIS POLICY DOES NOT COVER EARTHQUAKE OR FLOOD DAMAGE ** In return for timely payment and subject to all policy terms and conditions, we agree with you to provide insurance as stated in this policy, declarations, and every applicable form and endorsement. Also: - Amount of insurance limits shown are not stackable across locations or buildings; - With respect to Business Liability and Medical Expenses - each claim paid reduces the amount of insurance provided during the applicable annual period; and, - If coverage limits or deductibles are indicated "included" refer to policy provisions for coverage, conditions, and amount of insurance details. PREMIUM AND FEES Annual Premium $ 576.05 Terrorism - Certified Acts $ 3.80 Policy Fee - New Business $ 50.00 Total Annual Premium & Charges $ 629.85 SB DS 01 11 17 004100000000000295223041 0000C Risk Mancgmtent DMitimt REVIEiwE➢ 6 APPRQY® Sr: A, fi Auv44 112� ® Risk Management Specialist SECTION I - PROPERTY: Coverages, Forms, Limits & Deductibles Applicable for Specified Premises Premises/Location 1, Building 1 1056 CABRILLO PARK DR, B, SANTA ANA, CA 92701 Square Feet: 943 Building Limit Annual Increase: 6.0% Use: Immigration Solutions Coverage Business Personal Property (BPP) Business Income Accounts Receivable Arson Reward Debris Removal Extra Expense Fire Department Service Charge Fire Extinguisher System Recharge Fur, Jewelry or Patterns Theft or Damage Lock Replacement Pollutant Clean-up and Removal Valuable Papers and Records Form Number Limit Deductible BP 00 03 07 13 $15,000 $1,000 BP 00 03 07 13 12 Months 72 Hours BP 00 03 07 13 $10,000 $1,000 SB 04 02 05 15 $10,000 None BP 00 03 07 13 $25,000 $1, 000 BP 00 03 07 13 12 Months None BP 00 03 07 13 $2,500 None BP 00 03 07 13 $5,000 None BP 00 03 07 13 $2,500 $1,000 SB 04 06 05 15 $1,000 None BP 00 03 07 13 $10,000 $1,000 BP 00 03 07 13 $10,000 $1,000 SECTION I - PROPERTY: Coverages, Forms, Limits & Deductibles Applicable Per Policy Coverage Form Number Limit Deductible Computer Operations Interruption BP 00 03 07 13 $10,000 72 Hours Electronic Data Damage BP 00 03 07 13 $10,000 $1,000 Forgery or Alterations BP 00 03 07 13 $2,500 $500 Identity Recovery Coverage SB 04 51 12 17 $25,000 $500 SECTION II - LIABILITY AND MEDICAL EXPENSES: Coverages, Forms & Limits Applicable Per Policy Coverage Form Number Medical Expense - $10,000 Any One Person BP 00 03 07 13 Personal & Advertising Injury BP 00 03 07 13 Business Liability - Per Occurrence BP 00 03 07 13 Business Liability - Aggregate BP 00 03 07 13 Business Liability - Prods -Completed Ops BP 00 03 07 13 Damage to Premises Rented to You BP 00 03 07 13 Hired Auto & Non -Owned Auto - CA BP 06 86 05 17 SB DS 01 11 17 3 004100000000000295223041 0000C Limit IN LIAB LIMIT IN LIAB LIMIT $1,000,000 $2,000,000 $2,000,000 $100,000 IN LIAB LIMIT "6 MougemmtDhisim c�•A,^,, (&VIEWED&AppR mBr. ® Ruk Management SpeaAis[ SECTION III - ADDITIONAL INTERESTS Additional Insured: CITY OF SANTA ANA 20 CIVIC CENTER PLZ, PARKS, RECREATION AND COMMUNIT, SANTA ANA, CA 92701-4058 Additional Insured: RICHARD HEATH & ASSOCIATES, INC. 590 W LOCUST AVE, FRESNO, CA 93650-1079 Additional Insured: RANCHO SANTIAGO COMM COLLEGE DISTRICT 1530 W 17TH ST, SANTA ANA, CA 92706-3398 SB DS Ol 11 17 004100000000000295223041 OOOOC 5 MA Managmimt DMsfnn ReoEwED & APPROVE] BY: `1u1Il141' A+� Acw� ® Risk ManngementSpeci alist SECTION IV - ADDITIONAL FORMS: Applicable to All Premises and Coverages Coverage Form Number Calculation of Premium BP 05 01 07 02 Exclusion - Punitive Damages SB 04 03 08 14 Exclusion of Loss Due to By -Products of Production or Processing SB 04 17 08 14 Operations Cap on Losses From Certified Acts of Terrorism BP 05 23 01 15 Disclosue Pursuant to Terrorism Risk Insurance Act BP 05 15 01 15 California Disclosure Notice FNIC DN CA O1 06 Exclusion - Fungi or Bacteria (Liability) BP 05 77 01 06 Blanket Additional Insured & Subrogation Waiver SB 04 36 01 17 California Changes BP O1 55 OS 17 Privacy Policy PRIVACY POLICY O1 20 California Race, National Origin & Gender Form CA RNOGBPF 04 21 California Fraud Statement IL N 018 01 22 Exclusion - Access or Disclosure of Confidential or Personal BP 15 05 05 14 Information and Data -Related Liability Employment -Related Practices Exclusion BP 04 17 01 10 Exclusion of Certified Acts of Terror - Nuclear, Biological, BP 05 26 01 15 Chemical, or Radiological Equipment Breakdown Schedule SB DS 07 12 17 Equipment Breakdown Protection Coverage SB 04 53 12 17 Signed: SB DS O1 11 17 004100000000000295223041 0000C 7 by. Mark O. Davey, CEO RW�MuugeWWd DMSfan 170A�D & APPRovm 8v: A* ju AmA4 ® Risk Management SpeciAnt BUSINESSOWNERS SB04360117 THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ CAREFULLY. BLANKET ADDITIONAL INSURED AND BLANKET INSURANCE SUBROGATION WAIVER This endorsement modifies insurance provided under your BUSINESSOWNERS COVERAGE FORM Section II — Liability is amended as follows: The following is added to Paragraph C. Who Is An Insured: Any person or organization in a written agreement with you requiring indemnification is an additional insured on your policy with regard to their respective business interest. However, coverage applies only to liability due to "bodily injury", "property damage', or "personal and advertising injury' caused, in whole or part, by your acts or those performing operations on your behalf, or in connection with your franchise, equipment, or part of premises used by you and listed in your declarations, or, if a vendor, likewise when liability arises from "your product" as distributed or sold in the vendor's regular course of business. Coverage does not apply to liability resulting from the additional insured's sole negligence. And there is no coverage for structural alterations, new construction, and demolition steps performed by or on behalf of additional insureds. Insurance coverage afforded, limits, and the most we will pay on behalf of additional insureds is: 1. Only up to the extent permitted by law; 2. Not broader than your agreement with the additional insured; and, 3. Available under applicable limits of insurance shown in declarations; or whichever is less. However, insurance afforded to vendors does not apply to: 1. Any express warranty unauthorized by you; 2. Any product physical or chemical change made intentionally by the vendor; 3. Demonstration, installation, service or repair, except on vendors premises for your product's sale; 4. Package or label changes, use as a container, a part, or ingredient of another thing by the vendor; or, 5. Those who supply products, ingredients, or part of containers, in or affecting your products. In addition, agreements with additional insureds must be effective during the policy term; and, must be executed prior to "bodily injury", "property damage', or "personal and advertising injury". A person's or organization's status as an additional insured under this endorsement ends when your ongoing operations, occupancy or lease with that additional insured is complete. Section III — Common Policy Conditions is amended as follows: A. The following is added to Paragraph A. Cancellation 2. and supersedes any provision to the contrary: Additional insureds listed in declarations will be informed of coverage changes and given written notice at least: 1. 10 days before cancellation effective date if we cancel for premium nonpayment; or, 2. 30 days before cancellation effective date if we cancel for any other reason; and, 3. 30 days before expiration if we elect not to renew this policy. B. The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary: Primary And Noncontributory Insurance (Blanket Insurance Subrogation Waiver) This insurance is primary to, and will not seek contribution from, other insurance available to an additional insured provided: 1. The additional insured is a named insured under such other insurance; and, 2. You have a written agreement stating your insurance would be primary and would not seek contribution from other insurance available to the additional insured. SB04360117 Includes copyrighted material of Insurance Services Office, Inc. with its pennis 004100000000000295223041 0000C Risk Mnugenlmt Division REVIEWED 6 APPRWED BY: �i Risk Management Spedalis[ Karduz Nguyen CITYOFSANTAANA RISK MANAGEMENT d4-aaaa 4HUMAN RESOURCES Managing IMsh oftug,Positim Change 1 WORKERS' COMPENSATION DECLARATION (Name/Title) following declaration: hereby affirm under penalty of perjury, the I certify on behalf of VIETLA that during the term (Consultant/Company Name) of my contract for interpretation 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. Date: 06/01/2023 Print Name: Karduz Nguyen Print Title: CEO Signature: Telephone: 650-808-5121 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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. l: Risk Mgmt�lnsurance Requirements� WC Declaration 08152019 _ RlekMnugenantDlvieiun sry �n`^• "� REVIEWED 6 APPROVED Br. A+� Auwrlo Risk Managemem Specialist