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HomeMy WebLinkAboutMICHAEL BAKER INTERNATIONAL, INC (2)A-2020-076-05A �: PwA(I�e�Oel- /4)(SA)z MAYOR r+� Valerie Amezcua j MAYOR PRO TEM Jessie Lopez QID COUNCILMEMBERS N Phil Bacerra Johnalhan Ryan Hernandez ;;M David Penaloza Thai Viet Phan Benjamin Vazquez INSURANCE ON FILE WORK MAY PROCEED UNTIL INSI�R�ANNC�IRES CITY CLER((K;; DATE: CITY OF SANTA ANA PUBLIC WORKS AGENCY 20 Civic Center Plaza . P.O. Box 1988 Santa Ana, California 92702 www.santa-ana.ora April 10, 2023 Michael Baker International, Inc. 5 Hutton Centre Drive, Suite 500 Santa Ana, CA 92707 Attn: Kieler Smith, PE, Project Manager Re: Extension of Agreement for On -Call Water Resources Construction Management and Inspection Services Agreement No. A-2020-076-05 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CITY CLERK Jennifer L. Hall Pursuant to Section 3 ("Term") of the above -referenced Agreement, entered into by Michael Baker International, Inc., and the City of Santa Ana, dated April 21, 2020, the time period of the Agreement is hereby extended for an additional two-year period, from April 21, 2023 through April 20,2025. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, n Nabil Saba, P.E. Executive Director, Public Works Agency CITY OF SANTA ANA Kristine Ridge City Manager APPROVED AS TO FORM Braffon Salvatierra Deputy City Attorney ATTEST reMR, --- MICHAEL BAKER INTERNATIONAL INC. Tanya Bil kjian Vice President SANTA ANA CITY COUNCIL Valene Ami Jessie Lopez Thai Viet Phan Benjamin Vazquez Phil Bm,ard Johnathan Ryan Hernandez David Panels. Mayor Mayor Pro Tam, Ward 3 Wei Word Wasi Weis Ward6 samezcua,lijsanta-anam, sielooesrAsanta-ana.ora tpham5isanlaanaom Inaz,naz(alsanla-anaom obeesmadsarman, am mianhomandezapsaffle,anaers opens ... sasanla-anaoto Mazariego, Diana Subject: FW: Internal Notice of Compliance NOTICE OF COMPLIANCE (I[) tit_1EF: ITT I MIS P.V;F::01) IM I.t uE NA I III :1cREI:N1IN'1 ru 1 [IL( LERK uF 111N ( OL "( IL Contractor Michael Baker International, Inc. Name: Project TBD (067) Number: Project Extension of Agreement for On -Call Water Resources Construction Name: Management and Inspection Services Agreement No. A-2020-076-05 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 AUTOMOBILE LIABILITY GENERAL LIABILITY PROFESSIONAL LIABILITY WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 5/5/2023 7:43 PM POLICY EXPIRATION NUMBER DATE COI DATE FILE NAME Michael Baker International LLC - City 8AF419728401 08/30/2023 04/25/2023 of Santa Ana - 23042527060895- 570099137806.pdf Michael Baker International LLC - City GL0419728101 08/30/2023 04/25/2023 of Santa Ana - 23042527060895- 570099137806.pdf 03124806 08/30/2023 09/07/2022 WC419728201 08/30/2023 08/16/2022 MICHAEL BAKE R_EXP8.30.23.pdf NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Michael Baker International, Inc. Name: Project A-2020-076-05A Number: Project Extension of Agreement for On-Call Water Resources Construction Name: Management and Inspection Services Agreement No. A-2020-076-05 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 Michael Baker AUTOMOBILE LIABILITY BAP419728402 08/30/2024 08/18/2023 Int Inc COI.pdf Michael Baker E&O - PROFESSIONAL LIABILITY - PRIMARY 03124806 08/30/2024 08/18/2023 Int Inc COI.pdf City of Santa Ana_On-Call GENERAL LIABILITY GL0419728102 08/30/2024 08/18/2023 Envir - 570101186882 (2023-24).pdf WORKERS COMPENSATION AND EMPLOYERS' Michael Baker WC419728202AOS 08/30/2024 08/18/2023 LIABILITY Int Inc COI.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 11/17/2023 1:55 PM Holder Identifier : 7777777707070700077761616045571110776617006304557307553127673506210073641577147321120763415546177555207026100677235553074626231325277600754263357607677607704011752274530076727242035772000777777707000707007 7777777707070700073525677115456000733101507137103007122337352063001070332372420631110703222624306311107033237242073110070233373520731010702233635207311007023226253073111077756163351765540777777707000707007Certificate No : 570110778516 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/05/2025 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). 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. PRODUCER Aon Risk Services Central, Inc. Pittsburgh PA Office EQT Plaza ~ Suite 2700 625 Liberty Avenue Pittsburgh PA 15222-3110 USA PHONE(A/C. No. Ext): E-MAILADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # (866) 283-7122 INSURED 24319Allied World Surplus Lines Insurance CoINSURER A: 16535Zurich American Ins CoINSURER B: 26247American Guarantee & Liability Ins CoINSURER C: INSURER D: INSURER E: INSURER F: FAX(A/C. No.):(800) 363-0105 CONTACTNAME: Michael Baker International, Inc 5 Hutton Centre Drive Suite 500 Santa Ana CA 92707 USA COVERAGES CERTIFICATE NUMBER:570110778516 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, Limits shown are as requested POLICY EXP (MM/DD/YYYY)POLICY EFF (MM/DD/YYYY)SUBRWVDINSR LTR ADDL INSD POLICY NUMBER TYPE OF INSURANCE LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR POLICY LOC EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG X X X X GEN'L AGGREGATE LIMIT APPLIES PER: $2,000,000 $1,000,000 $10,000 $2,000,000 $4,000,000 $4,000,000 $250,000Deductible B 08/30/2024 08/30/2025GLO419728103 PRO- JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY SCHEDULED AUTOS HIRED AUTOS ONLY NON-OWNED AUTOS ONLY BODILY INJURY ( Per person) PROPERTY DAMAGE (Per accident) X X X BODILY INJURY (Per accident) $2,000,000B08/30/2024 08/30/2025 $100,000 COMBINED SINGLE LIMIT (Ea accident)BAP 4197284 03 Deductible EXCESS LIAB X OCCUR CLAIMS-MADE AGGREGATE EACH OCCURRENCE DED $10,000,000 $10,000,000 $10,000 08/30/2024UMBRELLA LIABC 08/30/2025AUC053258206 RETENTIONX X E.L. DISEASE-EA EMPLOYEE E.L. DISEASE-POLICY LIMIT E.L. EACH ACCIDENT $1,000,000 X OTH-ERPER STATUTEB08/30/2024 08/30/2025 AOS WC419728503B 08/30/2024 08/30/2025 $1,000,000 Y / N (Mandatory in NH) ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER N / AN WI WORKERS COMPENSATION AND EMPLOYERS' LIABILITY If yes, describe under DESCRIPTION OF OPERATIONS below $1,000,000 WC419728203 Per Claim0312480608/30/2024 08/30/2025 Claims Made $5,000,000Aggregate SIR $200,000 E&O - Professional Liability - Primary A SIR applies per policy terms & conditions $5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: MB Project Name: Environmental Services and Technical Studies, Agreement A-2020-076-05A. The City of Santa Ana, its officers, officials, employees and volunteers are included as Additional Insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. General Liability policy evidenced herein is Primary and Non-Contributory to other insurance available to Additional Insured, but only in accordance with the policy's provisions. A Waiver of Subrogation is granted in favor of the City of Santa Ana in accordance with the policy provisions of the General Liability, Automobile Liability, Umbrella Liability, Professional Liability and Workers' Compensation policies. CANCELLATIONCERTIFICATE HOLDER AUTHORIZED REPRESENTATIVECity of Santa Ana Attn: Water Resources Division (M85) 215 S Center St. Santa Ana CA 92703 USA ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Additional Insured – Automatic – Owners, Lessees Or Contractors THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy No. GLO 4197281-03 Effective Date: 08/30/2024 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A.Section II – Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured under a written contract or written agreement executed by you, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" and subject to the following: 1.If such written contract or written agreement specifically requires that you provide that the person or organization be named as an additional insured under one or both of the following endorsements: a.The Insurance Services Office (ISO) ISO CG 20 10 (10/01 edition); or b.The ISO CG 20 37 (10/01 edition), such person or organization is then an additional insured with respect to such endorsement(s), but only to the extent that "bodily injury", "property damage" or "personal and advertising injury" arises out of: (1)Your ongoing operations, with respect to Paragraph 1.a. above; or (2)"Your work", with respect to Paragraph 1.b. above, which is the subject of the written contract or written agreement. However, solely with respect to this Paragraph 1., insurance afforded to such additional insured: (a)Only applies if the "bodily injury", "property damage" or "personal and advertising injury" offense occurs during the policy period and subsequent to your execution of the written contract or written agreement; and (b)Does not apply to "bodily injury" or "property damage" caused by "your work" and included within the "products-completed operations hazard" unless the written contract or written agreement specifically requires that you provide such coverage to such additional insured. 2.If such written contract or written agreement specifically requires that you provide that the person or organization be named as an additional insured under one or both of the following endorsements: a.The Insurance Services Office (ISO) ISO CG 20 10 (07/04 edition); or b.The ISO CG 20 37 (07/04 edition), such person or organization is then an additional insured with respect to such endorsement(s), but only to the extent that "bodily injury", "property damage" or "personal and advertising injury" is caused, in whole or in part, by: (1)Your acts or omissions; or (2)The acts or omissions of those acting on your behalf, U-GL-2162-A CW (02 /19) Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. in the performance of: (a)Your ongoing operations, with respect to Paragraph 2.a. above; or (b)"Your work" and included in the "products-completed operations hazard", with respect to Paragraph 2.b. above, which is the subject of the written contract or written agreement. However, solely with respect to this Paragraph 2., insurance afforded to such additional insured: (i)Only applies if the "bodily injury", "property damage" or "personal and advertising injury" offense occurs during the policy period and subsequent to your execution of the written contract or written agreement; and (ii)Does not apply to "bodily injury" or "property damage" caused by "your work" and included within the "products-completed operations hazard" unless the written contract or written agreement specifically requires that you provide such coverage to such additional insured. 3.If neither Paragraph 1. nor Paragraph 2. above apply and such written contract or written agreement requires that you provide that the person or organization be named as an additional insured: a.Under the ISO CG 20 10 (04/13 edition, any subsequent edition or if no edition date is specified); or b.With respect to ongoing operations (if no form is specified), such person or organization is then an additional insured only to the extent that "bodily injury", "property damage" or "personal and advertising injury" is 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, which is the subject of the written contract or written agreement. However, solely with respect to this Paragraph 3., insurance afforded to such additional insured: (a)Only applies to the extent permitted by law; (b)Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured; and (c)Only applies if the "bodily injury", "property damage" or "personal and advertising injury" offense occurs during the policy period and subsequent to your execution of the written contract or written agreement. 4.If neither Paragraph 1. nor Paragraph 2. above apply and such written contract or written agreement requires that you provide that the person or organization be named as an additional insured: a.Under the ISO CG 20 37 (04/13 edition, any subsequent edition or if no edition date is specified); or b.With respect to the "products-completed operations hazard" (if no form is specified), such person or organization is then an additional insured only to the extent that "bodily injury" or "property damage" is caused, in whole or in part by "your work" and included in the "products-completed operations hazard", which is the subject of the written contract or written agreement. However, solely with respect to this Paragraph 4., insurance afforded to such additional insured: (1)Only applies to the extent permitted by law; (2)Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured; (3)Only applies if the "bodily injury" or "property damage" occurs during the policy period and subsequent to your execution of the written contract or written agreement; and (4)Does not apply to "bodily injury" or "property damage" caused by "your work" and included within the "products-completed operations hazard" unless the written contract or written agreement specifically requires that you provide such coverage to such additional insured. U-GL-2162-A CW (02 /19) Page 2 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. B.Solely with respect to the insurance afforded to any additional insured referenced in Section A. of this endorsement, the following additional exclusion applies: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: 1.The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or 2.Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. C.Solely with respect to the coverage provided by this endorsement, the following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV – Commercial General Liability Conditions: The additional insured must see to it that: (1)We are notified as soon as practicable of an "occurrence" or offense that may result in a claim; (2)We receive written notice of a claim or "suit" as soon as practicable; and (3)A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D.Solely with respect to the coverage provided by this endorsement: 1.The following is added to the Other Insurance Condition of Section IV – Commercial General Liability Conditions: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a.The additional insured is a Named Insured under such other insurance; and b.You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2.The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition under Section IV – Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E.This endorsement does not apply to an additional insured which has been added to this Coverage Part by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F.Solely with respect to the insurance afforded to an additional insured under Paragraph A.3. or Paragraph A.4. of this endorsement, the following is added to Section III – Limits Of Insurance: Additional Insured – Automatic – Owners, Lessees Or Contractors Limit The most we will pay on behalf of the additional insured is the amount of insurance: U-GL-2162-A CW (02 /19) Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 1.Required by the written contract or written agreement referenced in Section A. of this endorsement; or 2.Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms, conditions, provisions and exclusions of this policy remain the same. U-GL-2162-A CW (02 /19) Page 4 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy No.Eff. Date of Pol.Exp. Date of Pol.Eff. Date of End.Producer Add’l Prem.Return Prem. GLO 4197281-03 08/30/2024 08/30/2025 15939000 $ INCL $ Waiver Of Subrogation (Blanket) Endorsement U-GL-925-B CW (12/01) Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition: If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery. This waiver of rights shall not be construed to be a waiver with respect to any other operations in which the insured has no contractual interest. POLICY NUMBER: BAP 4197284-03 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are “insureds” for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: MICHAEL BAKER INTERNATIONAL LLC Endorsement Effective Date: 08/30/2024 SCHEDULE Name Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: BAP 4197284-03 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: MICHAEL BAKER INTERNATIONAL LLC Endorsement Effective Date: 08/30/2024 SCHEDULE Name(s) Of Person(s) Or Organization(s): ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the “accident” or the “loss” under a contract with that person or organization. WC 00 03 13 (Ed. 4-84)  1983 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION. Policy # WC 4197282-03