HomeMy WebLinkAboutRodney Rooney Productions 1
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AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
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Return form to the Deputy Clerk of the Council (M-30). Ca11647-6520 if you have any
questions.
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The agreement with ( ,~ -3
was completed on ~ ~~~,~~ ZC7C~ ~~ ,and final payment has been made.
AGREMNT
_ NAME NUMBER
ROONEY, RODNEY PRODUCTIONS ~N-2003-031
iNC DBA "OUT & ABOUT TV"
_-- --_
ROONEY, RODNEY PRODUCTIONS ;N-2003-031-01
INC DBA "OUT & ABOUT TV"
i
Department: ~c~.'t~;s~.cc, ~~~o n~.~- ~G~
Signature: -~~
Date: `--~-`'~ ~~~ ~C~
~ ~~ ` ~ - /~~ a~i0~~~'u°'" City of Santa Ana
Revised 4-16-87 ~ ~''~ „`_° ,~ Clerk of the Council
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UNTIL Ii~SU~ ~lq~ ! ;XP]RES
'/__2/.2-_:_/~.~ , N-2003-031
~AI[: ,~i/c ~ CONSULTANT AGREEMENT
THIS AGREEMENT, made ~d entered into this ~day of ~ , 2003 by
~d between Rodney Rooney Productions Inc. dba "Out & About TV," a California corporation
(hereinaker "Consultant"), and the City of Santa Aha, a charter city and municipal co¢oration
organized and existing under the Constitution and laws of the State of California (hereinafter
"City").
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the field of
video production and streaming.
B. Consultant represents that Consultant is able and willing to provide such services to the
City.
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 consulting firm in the 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 follo;vs:
1. SCOPE OF SERVICES
a. Consultant shall perform those services as set forth in Exhibit A to this Agreement.
b. Consultant shall retain all right, title and interest in and to ail goods and products
produced hereunder, including, without limitation, the City's streaming video(s). At City's
election, City may purchase copies, for distribution only, of the City's 120 second streaming
video segment for City's distribution and use for a price agreed upon ;vith Consultant, not to
exceed $400.00.
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for the services
identified in Exhibit A, the rates and charges identified in Exhibit A. The total sum to be
expended for the services specified on Exhibit A, shall not exceed $ 7,500.00 plus a $400.00
contingency for a total amount not to exceed $7,900.00 during the term of this Agreement.
Provided however, use of the contingency amount shall be pre-authorized by the Executive
Director of City.
b. Payment by City shall be as follows:
Fifty percent (50%) upon execution of the Agreement; and
Fifty percent (50%) upon completion of video segment.
3. TERM
This Agreement shall commence on the date first written above and terminate on April
30, 200~, unless terminated earlier in accordance with Section 12, below. In order to provide
continuous uninterrupted service to City by Consultant, this Agreement shall cover services
rendered by Consultant from February 1, 2003 to the termination of the Agreement. The term of
this Agreement may be extended upon a writing executed by the Executive Director of
Community Development Agency and the City Attorney.
4. INDEPENDENT CONTRACTOR
Consultant 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
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
employees and shall be responsible for all applicable withholding taxes.
5. 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. Commercial General Liability Insurance. Consultant shall maintain commercial
general liability insurance naming the City, its officers, agents, volunteers, and employees as
additional insured(s) and shall include, but not be limited to protection against claims arising
from bodily and personal injury, including death resulting therefrom and damage to property,
resulting from any act or occurrence arising out of Consultant's operations in the performance of
this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance
shall be not less than the following: single limit coverage applying to bodily and personal injury,
including death resulting therefrom, and property damage, in the total amount of $1,000,000 per
occurrence. Consultant shall supply City with a fully executed additional insured endorsement in
substantially the form attached hereto as Exhibit B upon execution of this Agreement and shall
be approved in form by the City Attorney.
2
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for
owned, hired and non-owned automobiles.
c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300
of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against
liability for worker's compensation or to undertake self-insurance. Prior to commencing the
performance of the work under this Agreement, Consultant agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
d. If Consultant is or employs a licensed professional such as an architect or engineer:
Professional liability (errors and omissions) insurance, with a combined single limit of not less
than $1,000,000 per claim.
e. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(i) Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
(iii) Certificates and policies shall state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
f. If Consultant fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City ~vith required proof that insurance has been procured
and is in force and paid for, the City shall have the right, at the City's election, to forthwith
terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its
time and materials expended prior to notification of termination. Consultant waives the right to
receive compensation and agrees to indemnify the City for any work performed prior to approval
of insurance by the City.
6. INDEMNIFICATION
Consultant agrees to indemnify, defend and hold harmless City, its officers, agents,
volunteers and employees from any and all loss or damage, and ti'om any and all suits, actions
and claims filed or brought by any person or persons, however caused, arising out of
Consultant's and Consultant's employees' and subcontractors' negligent performance or failure
to perform, any and all things necessary to and required to be done by Consultant, pursuant to the
provisions of this Agreement.
7. CONFIDENTIALITY
If Consultant receives 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 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.
8. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have interests, direct
or indirect, which would conflict in any manner with performance of services specified under
this Agreement.
9. 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 telefacsimile or other
telegraphic communication in the manner provided in this Section, to the following persons:
To City:
Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
telefacsimile (714) 647-6956
With courtesy copies to:
Executive Director of Community Development Agency
City of Santa Ana
20 Civic Center Plaza (M-25)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6549
and,
4
City Attorney
City of Santa Ana
20 Civic Center Plaza (M-29)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6515
To Consultant:
Liz Rooney, President, CEO
Out & About TV
P.O. Box 15373
Newport Beach, CA 92659
Telefacsimile 949-722-0862
A party may change its address by giving notice in writing to the other party. Thereafter,
any notice, tender, demand, delivery, or other communication shall be addressed and transmitted
to the new address. If sent by mail, any notice, tender, demand, delivery, or other
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 telefacsimile, any notice, tender, demand, delivery, or
other communication shall be effective or deemed to have been given twenty-four (24) hours
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, fbderal,
state, County or City holidays shall be excluded.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, 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. 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, that terms and conditions hereof, shall not bind or obligate Consultant nor
the City. Each party to 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.
11. 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
the 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.
12. TERMINATION
This Agreement may not be terminated by either party. However, if the City does not approve
the final version of the 120 second video segment, said segment shall, upon City's request, be cut
from the final production.
13. DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital
status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited
by applicable law, in the recruitment, selection, training, utilization, promotion, termination or
other employment related activities. Consultant affirms that it is an equal opportunity employer
and shaI1 comply with all applicable federal, state and local laws and regulations.
14. JURISDICTION - VENUE
This Agreement and all questions relating to its validity, interpretation, performance, and
enforcement shall be governed and construed in accordance with the laws of the State of
California. 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. Both 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.
15. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, 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 States, the State of California,
the City of Santa Ana and all other governmental agencies. Consultant shall notify the City
immediately and in writing of her inability to obtain or maintain such permits, licenses,
approvals, waivers, and exemptions. Said inability shall be cause for termination of this
Agreement.
16. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow has the power,
authority and right to bind their respective parties to each of the terms of this Agreement, and shall
indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to
City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set
forth in the body of this Agreement.
1N WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
Clerk of the Council
CITY OF SANTA ANA
(~~~L REAM
City Manager
APPROVED AS TO FORM:
JOSEPH W. FLETCHER
City Attorney
Laura Sheedy /
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
CONSULTANT
Jot~ 15. Reekstin
Executive Director of the
Community Development Agency
Employer ID # or Individual SS #
01~11/2003 08:27 949-722-0862 OUT AND ABOUT I'q ~ PAGE 02
January l0, 2003
Patricia Nunn
20 Civic Center Plaza
Santa Aua, CA 92702
Re: Video Production Services
Dear Patty:
. Thank you for selecting Rodncy Rooney Productions, Inc. DBA "Out & About TV" (the
"Company") to produce your video infomercial advertising your business. Tiffs agreement will
outline the terms of the Company's services and our respective obligations to one another.
The Company has been engaged by City of Santa Ann ("YOU") to produce a "streaming"
video segment o£approximately One-Hundred Twenty (120) seconds in length which will
consist of an infomercial advertising your business (the "¥id~o Se~menf').' The Company will
shoot, script and produce the Video Segment as more fully described on Exhi"oit "~' tS this
agreement. You will select the features and aspects of your business to be the subject of the
Video Segment, subject to the suggestions and reasonable approval of'the Company.
The Video Segment will be aired on selected interact websites under the control of the
Company, and other medium-q, as value-added (at the discretion of the Company), for a period of
twelve (12) months from the completion of the production of the Video Segment. In addition,
during the twelve month period, all or a portion of the Video Segment will be included in the
entertainment program being produced for the Anaheim/Orange County Visitor & Convention
Bureau (the "Bureau"), tentatNely entitled "Out&About O.C." (the "Eh ' am"),
if you are a member of'the Bureau. The Company will edit the Video Segment as it deems
appropriate for inclusion in the Entertainment Progran~. Of course, the Company cannot be
liable for the interruption in any streaming of the Video Segment as a result of events or
proble~ms beyond its control.
The Company v~ll not be responsible for any content of the Video Segment provided by
you, whether in the script or video. You represent that all information and materials to be
pro'Wded by you to the Company will be accurate, and no other person shall have any interest
therein.
EXHIBIT
81/11/2883 08:2? 949-722-08G2 OUT ~ND ~EOUI IV ~ ,. P~65 83
Page 2
The Company's fee for airin~disseminating the Video Segment az described above shall
be Seven-Thousand Five-Hundred Dollars ($7500) due and payable upon the execution of this
agreement.
Ali payments under this agreement should be made payable to "Out & About TV."
In the course of producing, scripting and shooting the Video Segment, you agree to
comply with all reasonable requests of the Company, and to provide access to all documents and
facilities reasonably necessary for the Company to perform its obligations under this agreement.
You agree to meet all scheduling deadlines and requirements, and to have all persons and shoot
areas available at the time designated by the Company. You will also obtain any necessary
permits and/or releases required in connection with the Video Segment shoot.
In order to produce the Video Segment in a professional manner, the Company may
request that you post at various locations in the shoot area, copies of notices of the impending
fil.ming (to be supplied by the Company), prior to the scheduled Video Segment shoot.
The Video Segment, and all copies thereof, and all work product and materials relating to
the Video Segment, shall be and remain, the exclusive properBt of the Company. You agree not
to use, or permit the use of, for any purpose, any portion of the Video Segment without the prior
written consent of the Company. You will not duplicate, or permit the duplication of, the Video
Segment, or otherw/se permit any public display thereof. The Company reserves the right to use
portions ofthe Video Segment in other programs, videos, and other productions of the Company,
without payment, obligation or liability to you.
This agreement contains our entire agreement regarding the Video Segment. It may be
amended only in a writing executed by both parties. California law shall govern the terms of our
agreement, with the Superior Court of California, County of Orange, being the sole jurisdiction
and venue for aay disputes. Attorneys' fees and costs shall be awarded to the prevailing party in
any dispute.
If the foregoing is acceptable, please execute a copy of this agreement where indicated,
and return it to the undersigned as soon as possible.
Very truly yours,
OUT & ABOUT TV
'~ 8'1./&Z/2803 88:27 949-722-8~62 OUT AND ,~BOUT TV '-, PC, GE 84
Page 3
AGREED and ACCEPTED tbJs 10m day of January 2003, at Santa Aha, Cal/fornia.
BY:
NAME:
TITLE:
81~11/2003 08:27 949-722-8862 OUT AND ABOUT TV ~ ~, PAGE 05
EXHIBIT "A"
120-second video segment
highlighting selected features of City of Santa Ana
Production Includes:
*Scripting of segment
Previous marketing items will be furnished by City of Santa Aha
*Script Approval
*Storyboard
*Storyboard Approval
*Scheduling of Shoot
*Production
*Post-Production
*Finished Product Approval (ix)
EXHIBIT B
ADDITIONAL INSURED ENDORSEMENT
FOR COMMERCIAL GENERAL LIABILITY POLICY
Insurance Company
This endorsement modifies such insurance as is aflbrded by the provisions of Policy
# relating to the following:
I. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its
officers, employees, agents, volunteers and representatives are named as additional insureds
("additional insureds") with regard to liability and defense of suits arising from the operations
and uses performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by or on
behalf of the named insured, such insurance as is afforded by this policy is primary and is not
additional to or contributing ~vith any other insurance carried by or for the benefit of the
additional insureds.
3. This insurance applies separately to each insured against whom claim is made or
suit is brought except with respect to the company's limits of liability. The inclusion of any
person or organization as an insured shall not affect any right which such person or organization
would have as a claimant if not so included.
4. With respect to the additional insureds, this insurance shall not be cancelled, or
materially reduced in coverage or limits except after thirty (30) days written notice has been
given to the Clerk of the Council, City of Santa Ana, 20 Civic Center Plaza, Santa Ana,
California 92701.
(Completion of the following, including countersignature, is required to make this endorsement
effective.)
Effective
Policy #
Issued to
., this endorsement form as a part of
Named Insured
Countersigned by
Authorized Representative
A¢ORD CERTIFICATE OF LIABILITY INSURANCE
PRODUCER (949)348-7400 FAX (949)348-2373
Al'pel Insurance Agency, Inc.
License #0746539
26522 La Alameda, Suite i90
Mission Viejo, CA 92691
INSURED OUT AND ABOUT T.V.
P.O.BOX - 15373
NEWPORT BEACH, CA 92659-5373
OF J DATE (MM/DD/YY)
O4/01/2003
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
COVERAGES
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 AFFQRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
LTR TYPE OF INSURANCE POLICY NUMBER
DATE (MM/DD/YY) DATE (MMIDD/YY) LIMITS
GENERAL LIABILITY ~A5040153703 04/02/2003 04/02/2004 EACH OCCURRENCE $ 1,000,000
~-- COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ 1,000,000
I CLAIMS MADE ~T~ OCCUR MED EXP (Any one person) $ 10,000
A __ PERSONAL & ADVINJURY $ i ~ 000 , 000
J GENERAL AGGREGATE $ 2, 000,000
~-N'L AGGREGATE LIMIT APPLIES PER PRQDUCTS - COMP/DP AGG $ 2,000,000
AUTOMOBILE LIABILITY PAS0401S3703 04/02/2003 04/02/2004 COMBINED SINGLE LIMIT
-- ANY AUTO (Ea accident) $
1,000,000
ALL OWNED AUTOS
BODILY INJURY
-- SCHEDULED AUTOS (Per person) $
A ~- HIRED AUTOS
-- BODILY INJURY
X NON OWNED AUTOS (Per accident) $
-- PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO i ,k?~ ~ [ AuToOTHER THANoNLY: EAACCAGG $$
EXCESS LIABILITY ~ ~ ....... AGGREGATEEACH OCCURRENCE $$
I OCCUR ~ CLAIMS MADE
$
WORKERS COMPENSATION AND i¢~,~L,~,~_s j i~~.
EL DISEASE POLfC~J~-T]'~
OTHER PA5040153703 04/02/2003 04/02/2004 Limit:~$40,000
A ~roperty Special Form
Deductible: $ 250
:ertificate holder is listed as additional insured per the attached endorsement.
~TE HOLDER J I ADDITIONAL INSURED; INSURER LETTER
CANCELLATION
The Community Redevelopment Agency of the
City of Santa Ana&
City of Santa Aha
Attn: Deborah Sanchez
20 Civic Centerr Plaza M-25
Santa Ama, CA 92701
FAX: (714)647-6549
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~i~(~-~'~Al~~ MAIL
~ 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
AUTHORIZED REPRESENTATIVE
Tony Alessandra/KEVIN
ADDITIONAL INSURED ENDORSEMENT
FOR COMMERCIAL GENERAL LIABILITY POLICY
Insurance Company
This endorsement modifies such insurance as is afforded by the provisions of Policy
# D,~coDq 01 ~3'TtD ~ relating to the following:
1. The Community Redevelopment Agency of the City of Santa Ana, and the
City of Santa Ana, both located 20 Civic Center Plaza, Santa Ana, California 92701; and
their respective officers, employees, agents, volunteers and representatives are nan~ed as
additional insureds ("additional insureds") with regard to liability and defense of suits
arising from the operations and uses performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by
or on behalf of the named insured, such insurance as is afforded by this policy is primary
and is not additional to or contributing with any other insurance carried by or for the
benefit of the additional insureds.
3. This insurance applies separately to each insured against whom claim is
made or suit is brought except with respect to the company's limits of liability. The
inclusion of any person or organization as an insured shall not affect any right which such
person or organization would have as a claimant if not so included.
4. With respect to the additional insureds, this insurance shall not be
cancelled, or materially reduced in coverage or limits except after thirty (30) days written
notice has been given to the Community Redevelopment Agency of the City of Santa
Ana, 20 Civic Center Plaza (M-25), Santa Ana, California 92701.
(Completion of the following, including countersignature, is required to make this
endorsement effective.)
Effective 0~2'/L003 ~ Oq/o 2.,/z..ao q ,thisendorsementformasapartof
Policy # Pl~'~ 0 qO I~'~t-'40.~
Issuedto .~ofl~"l ~.o~lxt~ pR.~aa~t',,..g ~..~'~t- ~8~: od'~-~ ,~o~'Je' ~. [/.
.t .,I Named Insured
Countersigned by
~d Representative