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HomeMy WebLinkAboutLOPEZ, RAFAEL 1AGREEMENT TERMINATION 2005- Please complete this form when the attached agreement is no longer in effe`e ` -tH- Return form to the Deputy Clerk of the Council (M -30). Call 647 -6520 if you have any questions. The agreement with Lopez- — O's- '% was completed on to 13 d f and final payment has been made. Department: { -sii' Signature: \,� I AXV) Date: U hd o City of Santa Ana Revised 4 -16 -87 Clerk of the Council • INSURANCE ON F WORK MAY PROLE) UNTIL INSORAN': XPIRES N- 2003 -057 rc ZZ L�3 C • fJJ(sq CLERK OF OU CIL CONSULTANT AGREEMENT DATE 5��3�G THIS AGREEMENT, made and entered into this ZI day of 2003 by and between Rafael Lopez, an individual (hereinafter "Consultant "), and the Ci of Santa Ana, a charter city and municipal corporation 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 karate instruction. B. Consultant represents that Consultant 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 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 follows: 1. SCOPE OF SERVICES Consultant shall provide karate instruction at the El Salvador recreation Center located in Santa Ana two days a week for a minimum of one hour per class. There shall be a maximum of 25 students per class. Age range of participants is 5 years — Adult. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rate of 70% of the paid registrations per month. The total sum to be expended under this Agreement, shall not exceed $ 10,000.00 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 111 �1 tiui This Agreement shall commence on the date first written above and terminate on October 31, 2003, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Executive Director of the Parks, Recreation and Community Services 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. 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 with 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 and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health, and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or 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. 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 the Parks, Recreation and Community Services Agency City of Santa Ana 888 W. Santa Ana Blvd Ste 200 Santa Ana, California 92702 telefacsimile (714) 571 -4235 M an 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: Rafael Lopez 15811 Pasadena Avenue #28 Tustin, CA 92780 714- 832 -1951 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, federal, 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 be terminated by the City upon thirty (30) days written notice of termination. 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 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. 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 shall 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 government 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. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA PATRICIA E. HEAL AVID N. REAM Clerk of the Council City Manager APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attom By: i(✓� t Cristine aw Assistant City Attorney RECOMMENDED FOR APPROVAL: CONSULTANT 1 Jori `Rip" Ribble Executive Director of the Parks, Recreations and Community Services Agency Rafae opez ©5 —acs -- 3280 Employer ID # or Individual SS # EXHIBIT B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy F:3 relating to the following: 1. 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 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 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 -e .0 , /713d ACQJgt . `CERTIFICATE OF LIABILITY'' INSURANCE _ =4,,86 III, 'L" "1.1 PRODWER �- THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION Witness & eellneaa :Lnauranee ONLY AND CONFERS NO RIGHTS UPOPI THE CERTIFICATE Agency H ULUEKIHI$ 4:: 1': RTIFIGA7EDOESNO7AMEND ,EA:fILNGOR 390 Stevens Ave., Hirst Floor ALTER THE COVERAOE AFFORDED BY THE POLICIES BELOW. - Solana BaACh CA 92075 phone:R00 -395 -80755 1ex1858 -519 -0022 i iINSURERS AFFOROINUOOVERAGC NAIC0 INSURED -- ,NSVRER A liQeC ialty Kationa Zuouranca iNWIERR Y404619 Rafael Lopez t 10 -22 -02 1581 eva9na Ave, wNS3VuRREEA R Co: Tuft n CA 92790 ----- --- ..__ -_•. _.,.._,—.._-----}------- �- M f INSURER THE PUI.ItIESS OF MURANCC I.$TCDBELOWHAVE P,EEf;iS$11ED';f+TNF.»lHCkEG NALAiD MOVE FOR THE POLICY FEN1001P ;D "GATED. NO;WI'M$TANDINO ANY RCGJRtEMENT, TERM OR WNDITION OF ANY CONTk,IO1 OR OTHER DOGJNYNT WITH REEPRCT TO W! 111tH T il3 CLKr t$)7L MAY SP 1531JED OR MAY PERTAIN, THE IPAAURA 4ZE AFKrROEC SY THF_ POt.rVES UESCkIBEO HERE IA L, ^SUBJECT TO 41,L TNC TERMS, f AGU.S10T14 AND CCNVIVI -*U CP 3UOI1 POLICIEB AGGRE(UITE LIMITS SHOWN MAY HAVE BEEN REDIgFtl BY PAID CLAIMS MLIr4EFFRCTWE R IN3ftt TYPE Of WSURANOE POLAh NUMaER OATEf n^r DATE NM LIMITS GENERAL LIABILITY I FACHDCCU41RENCE t 1; OO�.000 A ][ COMMERCIAL U1N >I:4L LIAB1el1'r 1 3X'1.12 @45.1 02 10/.72/03 � 10 /d'.d /D pgEM15ES (ED PwwenColl $100.000 _ C!AIMS WDL'. OCrUR I MED EX °(Any nne permit)_ 52, 500 A -.$ MiaC.FrDfea110AA1 .�..._ ' PFR80NAL S ADV INJLRY IS 1, 000, 000 1 DENIER ALAGGREGATE $3,000.000 I `GEN'L AOOREOATtLMI7'APP E »PER: - PRODUCTS- COMP/OP AOO $1,000,000 ` i Y IDY AIETUYObILE LIABILITY _ -7-- - —1 COM6IWN D`kNGLE LIMIT L �ANYALITD I TEA etck9r11 - ALL OWNWAur0b F SCPIEDULED AUTOS (Fwp.,iN.) ' (Per Perenn) - •- y�•� -� - HIRED ALMO5 f pODILY NJURV 1potmaleen0 E NON- OWNEDAUTDS : PROPERTY CAMAGE r (PPS ULddent) �' - - - -- - -- GARAOE LMSIlJ7Y -- I DEN " b I AUTO ONLY, EAACC! ANY AUfO CTHEN THAN EA At b AUTQ ONLY AuG IS EXCeeauMnla:LLALI..euuTV' ;enekoccu� - RaElre �$ -- OGCUH J ClA1M$ MADE I i AGDREOr1TF_ • ^_ { T APPZOV' t. , iti „r4 5 -Q FUR DEDUCTIBLE ' WORKERS COMPWATA)NANO i I H- ORY 1.10115 EMPLOYERS' Le ULfT' 8 I 7 -ER CL EACH ACCIDENT -- -- g ANY PNOPRIETGRP ARTNEPJEXECUTIVCP()III OyFFICLekL''MOVEMVXCLUDEO? i �'�TIOTp V - -- 11-1.. DISCI AE -FA EraPIOrCEIE SPECIAL P�FO�VI °17N9 h &ax �EL DISEASE . PDLiGV LIMIT b OTHER - A sexual Abuse 3x'Gi.a64s1' -02 i 100,000 300,000 OESCR3PTION OF OPERATIDND I LOCATIONS / VEHICLES! EXCLWIDAS ADDED DY tN0OR8GMENT/ 9PP,OIAL PROV{biONft It in understood and agreed that the following entity is added as an additional insured but only as respects 'Jhe operations of tho uamod insured {except that liability resulting from the 1 additional insureds sole negligence The City of Banta Ana 20 Civic Center Fleas Santa Ana CA 92701 a&rfrav Z. VsIck �1 CE'S'TeAA 4140141-0 ANY OF THB AGOYE OEECRIGEiD POLICIES RE CANCELLED BEFORE THE EXMKATIDN DATE THEAEOP. THE 184UING INSURER WIL6 011m MAIL 30 DAYS WRITTEN NOTIDE TD THE GCH?TIPICNE HOLDER NAMED W THE L.EF T, ��� The City of Banta Ana 20 Civic Center Fleas Santa Ana CA 92701 a&rfrav Z. VsIck 04104/2003 13:46 734 -554 -5134 n &r 91 03 .rri!!P PUBTC 4UTr1 PtESTSTre lnturaccc(;wa,Yan:` This endotaelr nt mudifies such roam rntee as is afforded b3 the provisionz of F:,bcq fi _-, 4;�,fyZ��±l, l.rclatin� to the foilowing I. IN Ciro of Santa Ana, 20 t;ivc ( .meter Rua. 5mttn ara, Cai:farni 9270; i itn 02,"m. eniployaes, agedts, volunteers and rwiresentatives arc noint(l u5 o tiitiapw insureds (" additiona) nsureds") with regard to!iahility and datonse 04 slf,% arising tro» the operation; and uses performed by or on behalf of ilic named ;rtsu;ed. 2 Witb respect tt, aaims ariaiag out of the ope:at:ors anu am pGff rnned by or a: behalf 'ofthe naaned insured, such luirwe as is afforded by ties policy is mmptwry and is rut additional to ur cnnlribawig with any other in.wance carried av or fat r1w t >eacrm of thv addition trmirtnls. ;t, Ilms it:auranee apybus bulfwalely to each Insured ag& :Q31 Whom claim is made or mull Is brought except with respect in rite usimpanys limits of h &bility The inc)us,an oi' Any rerson Of o:ganirmtivn Ya an irksoml shtll twt affect any tight which such pers<91 t't of janiration Would have as a claimant if cot so imlorin,l. 4, With reapecl to the additional iasureds, this insurance shall IN he esitce'.;od, or maeerially reduced it) covctag0 or iirn b axcepl sfterthirly M) Jays wn�wtt twtice has been Oven ,n the City of SOMA Anti. 20 Civic Center Plana, Se vte Ana. C ai4O;Ax U101, (Completion of Ilse :'Allowing, includilig woxtler&tOsnaturc, is required to mike this rndmsemen! IaLkctive o Q 03 s _.. - - -_ - --- ihis cedctserncm form as a "ore :,f Policy rj7x�- _�"9.S Named Insured Cowtersiitn od b - !~- i pit zed Rcertesentat!ve l" AS ro r,ORA4 , �,ulv Citv Artomev PAGE 04 CERTIFICATE OF LIABILITY INSURANCE Fitness and Wellness Purchasing Group INSURED #1408689 Rafael Lopez AND Effective 10 -22 -02 MAILING 15811 Pasadena Ave. #28 ADDRESS Tustin, CA 92780 SPECIALTY NATIONAL INSURANCE A KEMPER COMPANY Policy Number 3XZ126461 -02 - IDEA Certificate Number 1408689 AGENT Fitness and Wellness Insurance Agency NAME AND 380 Stevens Avenue, #115 MAILING ADDRESS Solana Beach, CA 92075 800 - 395 -8075 - CA LIC OD28716 POLICY PERIOD: From 10/22102 To 10/22/03 TOTAL PREMIUM: _i60_00__ THIS CERTIFICATE OF LIABILITY INSURANCE FORMS A PART OF THE POLICY REFERENCED ABOVE. INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS ALL THE RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY. THE INSURANCE COVERAGE PROVIDED UNDER THIS CERTIFICATE IS SUBJECT TO ALL THE TERMS, CONDITIONS, AND EXCLUSIONS OF THE POLICY IDENTIFIED ABOVE. COVERAGES LIMITS OF INSURANCE $1,000,000 Each Occurrence Limit $ 100,000 $ 2,500 Damage to Premises Rented to You Limit - any one premises Medical Expense Limit - any one person Personal and Advertising Injury Limit - any one person or organiz. $1,000,00o Each Professional Incident General Liability $3,000,000 General Aggregate Limit (other than Products /Completed Operations) $3,000,000 Aggregate Limit - Professional Liability $3,000,000 Products /Completed Operations Aggregate Limit None $ 100,000 Hired Auto Liability Each Claim Sexual and /or Physical Abuse Liability $ 300,000 Annual Aggregate Limit - Sexual and/or Physical Abuse Liability None Each Employee Limit Employee Benefits Liability None Aggregate Limit - Employee Benefits Liability Retroactive Date Employer's Liability State(s) where this Insurance applies (Only available in the $ 100,000 Bodily Injury by Accident - Each Accident following States: ND, OH, $ 100,000 Bodily Injury by Disease - Each Employee VA, WA and WY) $ 500,000 Aggregate Limit - Fmnlovar's Liability Liquor Liability None Each Common Cause Limit None Aggregate Limit - Liquor Liability Classification and Premium' Rate Advance Premium Loc. No. Classification Code No. Premium 44311 Basis I Prom /Ops Prod /Comp Per Schedule Per Schedule on File Premi Prod /Comp Health or Per Schedule on File Exercise Clubs on File Form of Business. X Individual , Partnership _ Joint Venture Limited Liability Co. _ Organization, (not including a Partnership, Joint Venture or Limited Liability Co) Location of all premises you own, rent or occupy 1) Various 3) 2) 4) v _ IF YOU HAVE ANY QUESTIONS CONCERNING THIS CERTIFICATE CONTAC1Ta E S— AND WELL ESS INSURANCE AGENCY De1500LSS5- 8'0731r° Ieffrey E. Fri December 26, 2002- -__ -- C.Mhnri>ed Remmnentative - Date