HomeMy WebLinkAboutDAYLE MCINTOSH CENTER 2I
AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Sr. Deputy Clerk of the Council (M-30). Call 617-5238 if you have any
questions.
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City of Santa Ana
Revised 8-7-03 Clerk of the Council
AdKHn#ON FILE A-2004-087-16
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CLERK OF COUNCIL AGREEMENT BETWEEN THE CITY OF SANTA ANA AND
DATE: ll "I u`o4 DAYLE MCINTOSH CENTER FOR THE DISABLED FOR USE OF
COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS
jr This Agreement, is hereby made and entered into this 3rd day of May, 2004, by and
between the City of Santa Ana, a charter city and municipal corporation of the State of California
("CITY") and Dayle McIntosh Center for the Disabled, a California nonprofit corporation
("SUBRECIPIENT").
WITNESSETH
Recitals:
A. The CITY, as an entitlement recipient and grantee of the United States Department of
Housing and Urban Development ("HUD") Community Development Block Grant ("CDBG")
Program, desires to enter this Agreement with the SUBRECIPIENT for the expenditure of CDBG
funds in accordance with Title 24, Part 570 of Code of Federal Regulations 24 CFR 570.000, et seq.
("CDBG REGS"); and
B. CITY has applied for and received CDBG funds from HUD pursuant to Title I of the
Housing and Community Development Act of 1974, Public Law 93-383, as amended ("ACT"); and
C. The SUBRECIPIENT is a private nonprofit agency that has been selected by the CITY
to receive CDBG funds and administer such financial assistance; and to provide the services
described in "Exhibit A," in accordance with the schedule of performance included therein,
hereinafter referred to as "said program". SUBRECIPIENT represents that it is qualified and
willing to operate said program and certifies that the activities carried out with funds provided under
this Agreement will meet one or more of the CDBG program's National Objectives (24 CFR Part
570.208).
D. The CITY and SUBRECIPIENT have duly executed this Agreement for the expenditure of
such funds; and
WHEREFORE, it is agreed by and between the parties that the foregoing Recitals are a
substantive part of this Agreement and the following terms and conditions are approved and
together with all exhibits and attachments hereto, shall constitute the entire Agreement between the_
CITY and SUBRECIPIENT:
L SUBRECIPIENT'S OBLIGATIONS
A. Non -Profit Status - Representations and Warranties
(a) Authority. SUBRECIPIENT is a duly organized and existing non-profit corporation
in good standing and authorized to do business under the laws of the State of California.
SUBRECIPIENT has full right, power and lawful authority to accept the funding hereunder and
to undertake all obligations as provided herein and the execution, performance and delivery of
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this Agreement by SUBRECIPIENT has been fully authorized by all requisite actions on the part
of SUBRECIPIENT.
(b) Experience. SUBRECIPIENT is a qualified provider of the services to be provided
hereunder.
(c) Familiarity With Services Required. By executing this Agreement,
SUBRECIPIENT warrants that (i) it has thoroughly investigated and considered the services to
be performed and provided hereunder, (ii) it has carefully considered how the services should be
performed, and (iii) it fully understands the facilities, difficulties and restrictions attending
performance of the services under this Agreement.
(d) No Conflict. To the best of SUBRECIPIENT'S knowledge, SUBRECIPIENT'S
execution, delivery and performance of its obligations under this Agreement will not constitute a
default or a breach under any contract, agreement or order to which SUBRECIPIENT is a party
or by which it is bound.
(e) No Bankruptcy. SUBRECIPIENT is not the subject of any current or threatened
bankruptcy proceeding.
(f) No Pending Legal Proceedings. SUBRECIPIENT is not the subject of a current or
threatened litigation that would or may materially affect SUBRECIPIENT'S performance under
this Agreement.
(g) Application Veracity. All provisions of and information provided in
SUBRECIPIENT'S application for funding submitted to CITY including any exhibits are true
and correct in all material respects.
(h) No Pending Investigation. SUBRECIPIENT is not aware that it is the
subject of any current or threatened criminal or civil action investigation by any public agency,
including without limitation a police agency or prosecuting authority, that would relate to affect
performance of the Agreement or provision of services hereunder.
B. Amount of Grant and Quarterly Disbursement. The amount granted to
SUBRECIPIENT is $ 15,000 ("CDBG FUNDS"), and such funds shall be expended by
SUBRECIPIENT on or before June 30, 2005. The CDBG FUNDS shall be disbursed by CITY
to SUBRECIPIENT on a quarterly basis (October, January, April and July) subject to and upon
receipt and approval of a complete quarterly activity report from SUBRECIPIENT, with the final
payment subject to the satisfaction of the condition precedent of submittal of complete reporting
information due on or before July 15 of the applicable funding year, as hereinafter more fully set
forth. SUBRECIPIENT shall be obligated to perform such duties as would normally extend
beyond the term, including but not limited to obligations with respect to indemnification, audits,
reporting, data retention/reporting, and accounting.
C. Use of Funds. SUBRECIPIENT agrees to use all federal funds provided by CITY to
SUBRECIPIENT pursuant to this Agreement to operate said program, as set forth in "Exhibit A,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT'S failure to perform as
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required may, in addition to other remedies set forth in this Agreement, result in readjustment of the
amount of funds CITY is otherwise obligated to pay to SUBRECIPIENT hereunder.
D. Allowable Costs. SUBRECIPIENT agrees to complete said program on or before
June 30, 2005 and to use said funds to pay for necessary and reasonable costs allowable under the
federal law and regulations to operate said program. Said amounts shall include, but not be limited
to, wages, administrative costs, and employee benefits comparable to other similarly situated
employees. Other allowable program costs are detailed in the Budget, as set forth in "Exhibit B,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT shall use all income
received from said funds only for the same purposes for which said funds may be expended
pursuant to the terms and conditions of this Agreement.
E. Licensing. SUBRECIPIENT agrees to obtain and maintain all required licenses,
registrations, accreditation and inspections from all agencies governing its operations.
SUBRECIPIENT shall ensure that its staff shall also obtain and maintain all required licenses,
registrations, accreditation and inspections from all agencies governing SUBRECIPIENT's
operations hereunder. Such licensing requirements include obtaining a City business license, as
applicable.
F. Zoning_ SUBRECIPIENT agrees that any facility/property used in furtherance of
said program shall be specifically zoned and permitted for such use(s) and activity(ies). Should
SUBRECIPIENT fail to have the required land entitlement and/or permits, thus violating any local,
state or federal rules and regulations relating thereto, SU13RECIPIENT shall immediately make
good -faith efforts to gain compliance with local, state or federal Hiles and regulations following
written notification of said violation(s) from the CITY or other authorized citing agency.
SUBRECIPIENT shall notify CITY immediately of any pending violations. Failure to notify CITY
of pending violations, or to remedy such known violation(s) shall result in termination of grant
funding hereunder. SUBRECIPIENT must make all corrections required to bring the
facility/property into compliance with the law within sixty (60) days of notification of the
violation(s); failure to gain compliance within such time shall result in termination of grant funding
hereunder.
G. Separation of Accounts. All funds received by SUBRECIPIENT from CITY
pursuant to this Agreement shall be maintained in an account in a federally insured banking or
savings and loan institution with record keeping of such accounts maintained pursuant to applicable.
OMB Circular A-110 requirements. SUBRECIPIENT is not required to maintain separate
depository accounts for CDBG FUNDS; provided however, the SUBRECIPIENT must be able to
account for receipt, obligation and expenditure of CDBG FUNDS pursuant to applicable OMB
Circular A-110 requirements.
H. Audit Report Requirements. SUBRECIPIENT agrees that if SUBRECIPIENT
receives Three Hundred Thousand Dollars ($300,000.00) or more in federal funds,
SUBRECIPIENT shall have an annual audit conducted by a certified public accountant in
accordance with the standards as set forth and published by the United States Office of Management
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and Budget. SUBRECIPIENT shall provide CITY with a copy of said audit by October 1 of the
year following the program year in which this Agreement is executed.
I. Record Keeping/Reporting. SUBRECIPIENT shall keep and maintain complete and
adequate records and reports to assist CITY in meeting and maintaining its record keeping
responsibilities under the CDBG REGS, including the following:
(1) Records
a. Documentation evidencing program income requirements in
conformity with 24 CFR 570.504(b((2)(i), (ii) and 24 CFR 570.503(b)(3) and 24
CFR 570.208(a)(2)(B) of the income level of persons and/or families participating
in or benefiting by the SUBRECIPIENT program.
b. Documentation of the number of persons and/or families participating
in or benefiting by the SUBRECIPIENT program.
c. Household information shall include number of persons, identification
of head of household, race/ethnicity, and income verification.
d. Documentation of all CDBG FUNDS received from CITY.
e. Documentation of expenses as identified in the Budget Proposal,
including evidence of incurring the expense, invoices for goods or services, copies
of any and all contracts or documentation pertaining to costs for subcontractors,
plus all other invoices for which CDBG FUNDS were expended, and any payments
therefor.
f Any such other related records as CITY shall reasonably require or as
required to be maintained pursuant to the CDBG REGS.
(2) Reports
(i) Payment Request. Concurrently with the submittal of each
quarterly report, on or before the 15th day of October, January,
April and July, SUBRECIPIENT shall submit both: an original
invoice and true copies of invoices, receipts, agreements, copies
of any and all contracts or documentation pertaining to costs for
subcontractors or other documentation supporting and
evidencing how the CDBG FUNDS have been expended during
the applicable quarter.
(ii) Quarterly Activity Report: SUBRECIPIENT agrees to keep monthly
records of all ethnic and racial statistics of persons and families benefited by
SUBRECIPIENT in the performance of its obligations under this Agreement,
including, but not limited to, the number of low and moderate income persons
and households assisted in accordance with federal income limits, the number
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of female heads of households assisted, new program information and year-to-
date program statistics on expenditures, caseload and activities.
J. Access to Records. CITY and the United State Government and/or their representatives
shall have access for purposes of monitoring, auditing, and examining SUBRECIPIENT's activities
and performance, to books, documents and papers, and the right to examine records of
SUBRECIPIENT's subcontractors, bookkeepers and accountants, employees and participants in
regard to said program. CITY and the United States Government and/or their representatives shall
also schedule on-site monitoring at their discretion. Monitoring activities may also include, but are
not limited to, questioning employees and participants in said program and entering any premises or
any site in which any of the services or activities funded hereunder is conducted or in which any of
the records of SUBRECIPIENT are kept. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
K. Location of Records/Reuuired Length of Record Keeping. All accounting records,
reports, and evidence pertaining to all costs, expenses and the CDBG FUNDS of
SUBRECIPIENT and all documents related to this Agreement shall be maintained and kept
available at SUBRECIPIENT' S office or place of business for the duration of the Agreement and
thereafter for five (5) years after completion of an audit in conformity with the CDBG REGS's.
Records which relate to (a) complaints, claims, administrative proceedings or litigation arising
out of the performance of this Agreement, or (b) costs and expenses of this Agreement to which
CITY or any other governmental agency takes exception, shall be retained beyond the five (5)
years until complete resolution or disposition of such appeals, litigation claims, or exceptions. In
the event SUBRECIPIENT does not make the above -referenced documents available within the city
of Santa Ana, California, SUBRECIPIENT agrees to pay all necessary and reasonable expenses
incurred by CITY in conducting any audit at the location where said records and books of account
are maintained.
L. Compliance with Law/Program Income. SUBRECIPIENT acknowledges that the funds
being provided by CITY for said program are received by CITY pursuant to the ACT as amended
and that expenditures of these funds shall be in accordance with the ACT and all pertinent
regulations issued by agencies of the federal government, including, but not limited to, all
regulations found at Title 24 of the Code of Federal Regulations. Program income received by
SUBRECIPIENT shall be returned to CITY unless otherwise provided for in this Agreement.
— SUBRECIPIENT agrees to comply fully with all federal, state and local laws and court orders
applicable to its operation whether or not referred to in this Agreement.
M. Standing. SUBRECIPIENT shall be in good standing, without suspension by the
California Secretary of State, Franchise Tax Board and Internal Revenue Service. Any change in
the corporate status or suspension of SUBRECIPIENT shall be reported immediately to CITY.
N. Confidentiality. Without prejudice to any other provisions of this Agreement,
SUBRECIPIENT shall, where applicable, maintain the confidential nature of information provided
to it concerning participants in accordance with the requirements of federal and state law. However,
SUBRECIPIENT shall submit to CITY and or HUD or its representatives, all records requested,
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including audit, examinations, monitoring and verifications of reports submitted by
SUBRECIPIENT, costs incurred and services rendered hereunder.
O. Independent Contractor. SUBRECIPIENT agrees that the performance of
obligations hereunder is rendered in its capacity as an independent contractor and that it is in no way
an agency of CITY.
P. Violation of Terms and Conditions. SUBRECIPIENT agrees that if
SUBRECIPIENT violates any of the terms and conditions of this Agreement or any prior
Agreement whereby CDBG funds were received by SUBRECIPIENT, or if SUBRECIPIENT
reports inaccurately, or if on audit there is a disallowance of certain expenditures, SUBRECIPIENT
agrees to remedy the acts or omissions causing the disallowance and repay CITY all amounts spent
in violation thereof. If SUBRECIPIENT engaged in fraudulent activity to obtain and/or justify
expenditure of the CDBG funds granted hereunder, SUBRECIPIENT shall be required to reimburse
the CITY of all such funds that were obtained/spent under fraudulent circumstances.
Q. Equipment. SUBRECIPIENT agrees to maintain a record for each item of non -
expendable personal property acquired under the terms of this Agreement. Said record shall be
made available to CITY upon request. The term "non -expendable personal property" shall include
leased and purchased equipment.
R. Prohibited Use. SUBRECIPIENT hereby certifies and agrees that it will not use
funds provided through this Agreement to pay for entertainment, meals or gifts.
S. Lobbying. SUBRECIPIENT certifies that it will comply with federal law (31
U.S.C. 1352) and regulations found at 24 CFR Part 87, which provide that no appropriated funds
may be expended by the recipient of a federal contract, grant, loan or cooperative agreement to pay
any person for influencing or attempting to influence an officer or employee of any agency,
Member of Congress, or an officer or employee of a Member of Congress in connection with
awarding of any federal contract, the making of any federal grant or loan, entering into any
cooperative agreement and the extension, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement. SU13RECIPIENT shall sign a certification to that
effect in a form as set forth in "Exhibit C," attached hereto and by this reference incorporated herein.
SUBRECIPIENT shall submit said signed certification to CITY prior to performing any of its
obligations under this Agreement and prior to any obligation arising on the part of CITY to pay any
sums to SUBRECIPIENT under the terms and conditions of this Agreement.
If any funds other than Federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit a 'Disclosure Form to Report Lobbying," in accordance
with its instructions (see C-1).
T. Financial Interest. SUBRECIPIENT agrees that except for the use of CDBG funds
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to pay salaries and other related administrative or personnel costs, no persons who exercise or have
exercised any function with respect to CDBG activities assisted under the terms of this Agreement,
or who are in a position to participate in a decision-making process or gain inside information with
regard to such activities, may obtain a financial interest or benefit from a CDBG-assisted activity of
SUBRECIPIENT, either for themselves or those with whom they have family or business ties,
during their tenure or for one year thereafter. This prohibition applies to any person who is an
employee, agent, consultant, officer, or elected or appointed official of CITY, or of
any designated public agencies, or the SUBRECIPIENT.
U. Davis -Bacon Act. All laborers and mechanics employed by contractors or
subcontractors in the performance of construction work, including alterations and repairs, in excess
of $2,000.00, financed in whole or in part with federal funds shall be paid wages at rates not less
than those prevailing on similar construction in the locality as determined in accordance with the
Davis -Bacon Act, as amended, 40 U.S.C. sections 276a - 276a-5. Any such construction contract
shall include and comply with the required contract provisions and rules set forth in 29 C.F.R. §5.5.
Further, the payroll reports (along with the "Statement of Compliance') and basic records are
required to be maintained and submitted, or made available, pursuant to 29 C.F.R. §5.5(a)(3). No
payment, advance, grant, loan or guarantee of funds shall be approved by the federal agency unless
there is on file with the agency a certification by the contractor that the contractor and its
subcontractors have complied with the provisions of 29 C.F.R. §5.5. A breach of the contract
clauses in 29 C.F.R. §5.5 may be grounds for termination of the contract, and for debarment as a
contractor/subcontractor, as provided in 29 C.F.R. §5.12. Labor standards interviews/investigations
shall be made as necessary to assure compliance [29 C.F.R. §5.6(a)(3)].
V. Drug Free Workplace. SUBRECIPIENT certifies that it has established the following
drug-free workplace policy:
1. The unlawful manufacture, distribution, dispensing, possession or use of a
controlled substance is prohibited in the workplace for any employee involved in a federally funded
program.
2. As an employee working in conjunction with a federally funded program, the
employees of SUBRECIPIENT will be required to:
a) Abide by the terms above in statement 1.
b) Notify appropriate officials of SUBRECIPIENT and CITY officials of
any criminal drug statute conviction for a violation occurring in the workplace not
later than five days after such conviction.
3. The CITY and the United State Department of Housing and Urban
Development will be notified within ten days after receiving notice of any such violation.
4. Within 30 days of receiving such notice, appropriate personnel action will be
taken against such employee, up to and including termination.
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Each such employee shall be required to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal, state or local health,
law enforcement, or other appropriate agency.
II. CITY'S OBLIGATIONS
A. Payment of Funds. Upon execution of this Agreement by SUBRECIPIENT, CITY shall
pay to SUBRECIPIENT from CDBG funds, when, if and to the extent received from HUD, for
CITY's Fiscal Year CDBG program year amounts expended by SUBRECIPIENT in carrying out
said program for fiscal year 2004-2005 pursuant to this Agreement up to a maximum aggregate
payment of Fifteen Thousand Dollars ($ 15,000) in installments determined by CITY. Payments
shall be made to SUBRECIPIENT through the submission of invoices on a quarterly basis (October,
January, April and July) in a form prescribed by CITY, detailing such expenses. CITY shall pay
such invoices within thirty (30) days after receipt thereof provided CITY is satisfied that such
expenses have been incurred and documented within the scope and provisions of this Agreement
and that SUBRECIPIENT is in compliance with the terms and conditions of this Agreement.
B. Audit of Account. CITY shall include an audit of the account maintained by
SUBRECIPIENT in CITY's annual audit of all CDBG FUNDS in accordance with Title 24 of
the Code of Federal Regulations and other applicable federal laws and regulations.
C. Common Rule: Pursuant to CFR 85.40(a), the CITY manages the day-to-day
operations of each grant and subgrant supported activities. CITY staff has detailed knowledge of the
grant program requirements and monitors grant and subgrant supported activities to assure
compliance with Federal requirements. Such monitoring covers each program, function and activity
and performance goals are reviewed periodically.
D. Environmental Review: hi accordance with 24 CFR 58, the CITY is responsible for
undertaking environmental review and maintaining environmental review records for each
applicable project.
E. Performance Monitoring: CITY shall monitor the performance of the
SUBRECIPIENT against goals and performance standards required herein. Substandard —
performance as determined by the CITY will constitute non-compliance with this Agreement. If
action to correct such substandard performance is not taken by the SUBRECIPIENT within a
reasonable period of time after being notified by the CITY, contract suspension or termination
procedures will be initiated.
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II1. NONDISCRIMINATION
SUBRECIPIENT agrees that no person on the ground of race, age, color, national origin,
religion or sex will be excluded from participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity funded in whole or in part with CDBG funds.
IV. CONFLICT OF INTEREST
Pursuant to the conflict of interest requirements set forth in 24 CFR 576.57 and OMB
Circulars 1-102 and A-110, SUBRECIPIENT agrees that no officer, employee, agent or assignee of
CITY having direct or indirect control of any CDBG monies granted to the CITY, inclusive of the
subject CDBG FUNDS, shall serve as an officer of SUBRECIPIENT. Further, any conflict or
potential conflict of interest of any officer of SUBRECIPIENT shall be fully disclosed in writing
prior to the execution of this Agreement and said writing shall be attached and deemed fully
incorporated as a part hereof. Notice shall be sent by SUBRECIPIENT to CITY regarding any
changes or modifications to its board of directors and list of officers.
V. SPECIAL CERTIFICATION FOR RELIGIOUS ENTITIES
If SUBRECIPIENT is a religious entity, SUBRECIPIENT hereby agrees that in connection
with the provision of the services SUBRECIPIENT shall provide with CDBG funds, in accordance
with 24 CFR 570.2000):
A. SUBRECIPIENT shall not discriminate against any employee or applicant for
employment on the basis of religion and shall not limit employment or give preference in
employment to persons on the basis of religion.
B. SUBRECIPIENT shall not discriminate against any person applying for the services
SUBRECIPIENT agrees to provide under the terms of this Agreement on the basis of religion and
shall not limit such services or give preference to applicants for such services on the basis of
religion.
C. SUBRECIPIENT shall NOT provide religious instruction or counseling, conduct
any religious worship or services, or engage in any religious proselytizing, or exert any religious.
influence in the provision of the services in said program. The parties agree that this covenant is
intended to and shall be construed for the limited purpose of assuring compliance with respect to the
use of CITY funds by SUBRECIPIENT with applicable constitutional limitations respecting the
establishment of religion as set forth in the establishment clause under the First Amendment of the
United States Constitution and Article I, Section 4 of the California Constitution, and is not in any
manner intended to restrict other activities of SUBRECIPIENT.
D. Where the services to be provided under said program are rendered on property
owned by the primarily religious entity SUBRECIPIENT, CDBG funds may also be used for minor
repairs to such property which are directly related to the cost of rendering the services under said
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program, where the cost constitutes in dollar terms only an incidental portion of the CDBG
expenditure for rendering the services under said program.
VI.
SUBRECIPIENT agrees not to hire or permit the hiring of any person to fill a position
funded through this Agreement if a member of that person's immediate family is employed in an
administrative capacity by SUBRECIPIENT. For the purposes of this section, the term "immediate
family" means spouse, child, mother, father, brother, sister, brother-in-law, sister-in-law, father-in-
law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, niece, nephew, stepparent and
stepchild. The term "administrative capacity' means having selection, hiring, supervisor or
management responsibilities.
VII. NOTICES
Notices to the parties shall, unless otherwise requested in writing, be sent by U.S. Mail,
postage prepaid, and addressed as follows:
TO CITY: City of Santa Ana
Community Development Agency (M-25)
20 Civic Center Plaza
P.O. Box 1988
Santa Ana, California 92702-1988
TO SUBRECIPIENT: Dayle McIntosh Center for the Disabled
13272 Garden Grove Blvd.
Garden Grove, CA 92843
VIII. ASSIGNABILITY
None of the duties of, or work to be performed by, SUBRECIPIENT under this Agreement
shall be subcontracted or assigned to any agency, consultant, or person without the prior written
consent of CITY. SUBRECIPIENT must submit all subcontracts and other agreements that relate
to this Agreement to CITY. No subcontract or assignment shall terminate or alter the legal
obligations of SUBRECIPIENT pursuant to this Agreement.
IX. HOLD HARMLESS
SUBRECIPIENT shall indemnify, defend and save harmless CITY, its officers, employees,
agents, representatives and volunteers from and against any and all damages to or for loss of use of
property and for injuries to or death of any person or persons, including property and employees or
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agents of CITY, and shall defend, indemnify and save harmless CITY, its officers, employees,
agents, representatives and volunteers from and against any and all claims, demands, suits, actions
or proceedings of any kind or nature, including, but not by way of limitation, workers compensation
claims and including attorney fees and reasonable expenses for litigation or settlement, resulting
from or arising out of the negligent or wrongful acts, errors or omissions of SUBRECIPIENT, its
officers, directors, employees, agents, subcontractors and suppliers arising out of
SUBRECIPIENT's performance of this Agreement.
X. INSURANCE
A. In accordance with the provisions of Section 3300 of the Labor Code, if
SUBRECIPIENT has any employees it is required to be insured against liability for worker's
compensation or to undertake self-insurance. Prior to commencing performance of this
Agreement, SUBRECIPIENT agrees to obtain and maintain employer's liability insurance with
limits not less than $1,000,000 per accident. If SUBRECIPIENT has no employees, nor
workers' compensation coverage, it must execute a Declaration available from the CITY, and
update as is necessary.
B. SUBRECIPIENT shall undertake self-insurance, or shall obtain, at its sole cost, a
policy or policies of commercial general liability insurance, or equivalent form, with a combined
single limit of not less than $1,000,000 per occurrence.
Such insurance shall: (1) name the City of Santa Ana, its officers, agents,
representatives, employees and volunteers as additional insured's; (2) be primary with respect to
insurance or self-insurance programs maintained by the CITY; (3) contain standard separation of
insured's provisions; and (4) give to CITY prompt and timely notice of claim made or suit
instituted arising out of SUBRECIPIENT's operations hereunder.
SUBRECIPIENT shall: (a) prior to exercising any right under this Agreement,
furnish properly executed certificates of insurance and additional insured endorsement to the
CITY which shall clearly evidence all coverages required above; (b) provide that such insurance
shall not be materially changed or terminated except on 30 days prior written notice to the CITY;
(c) maintain such insurance for the period covered by this Agreement; and (d) replace such
certificates for policies expiring prior to the expiration of this Agreement.
XI. REVERSION OF ASSETS
A. Upon the expiration of this Agreement, SUBRECIPIENT shall transfer to CITY any
CDBG funds on hand at the time of the expiration of this Agreement as well as any accounts
receivable attributable to the use of CDBG funds. [24 CFR 570.503(b)(8).]
B. Any real property under SUBRECIPIENT's control that was acquired or improved
in whole or in part with CDBG funds in excess of $25,000.00 must either be:
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1. Used, where CITY has given written approval, to meet one of the national
objectives stated in 24 CFR 570.208 until five (5) years after expiration of this Agreement, or for
such longer period of time as determined to be appropriate by CITY; or
2. If not used in accordance with subparagraph A above, SUBRECIPIENT
shall pay to CITY an amount equal to the current fair market value of the property less any portion
of the value attributable to the expenditure of non-CDBG funds for acquisition of, or improvement
to, the property. Such payment is program income to CITY.
C. Subject to the obligations set forth herein, title to equipment acquired under the
terms of this Agreement will vest upon acquisition in SUBRECIPIENT. When said equipment
which has been acquired in accordance with this Agreement and all applicable regulations is no
longer needed for said program, disposition of said equipment will be made as follows:
1. Items of equipment with a current per unit fair market value of less than
$5,000.00 may be retained, sold or otherwise disposed of with no further obligation to CITY.
2. Items of equipment with a current fair market per unit value of $5,000.00 or
more may be retained or sold and CITY shall have the right to an amount calculated by multiplying
the current market value or proceeds from the sale by CITY's share of federal funds used to acquire
the equipment, in accordance with 24 CFR 85.32(e)(2).
D. SUBRECIPIENT hereby agrees, upon the demand of CITY, to execute,
acknowledge and deliver, or cause any person or entity who may have any claim to rights hereunder
or under any document, instrument or agreement executed in furtherance of the services and
activities to be performed hereunder, to execute, acknowledge and deliver, to CITY assignment(s),
quit claim deed(s) or such other and further instruments, documents and agreements as may be
necessary, in the sole and absolute discretion of CITY, to vest in CITY all of SUBRECIPIENT's
right, title and interest (if any it may have) in and to CITY, CDBG or other federal, state and/or
local accounts or program funds or allocation of funds to which CITY is or may be entitled, either
for its own account or as fiduciary or trustee for others, which were obtained for the purpose of the
performance of this Agreement or any previous agreements relating to the same subject matter or
activities as this Agreement, together with any instruments, loans, grants or advances by
SUBRECIPIENT on behalf of CITY, in furtherance of the activities hereunder or thereof.
SUBRECIPIENT's obligations and responsibilities set forth in this paragraph "XI.
REVERSION OF ASSETS," and in paragraph "XII. TERMINATION" and other requirements
pertaining to program income shall not be affected by the termination of this Agreement and shall
survive the date of termination of this Agreement for such period of time as CITY and/or HUD
deems necessary for the responsibilities, duties and obligations to be performed and completed to
the satisfaction of CITY and HUD.
XII. TERMINATION
A. This Agreement may be terminated on thirty (30) days' written notice by either
12
8/04
party. In the event of such termination, SUBRECIPIENT shall only be entitled to reimbursement
for approved expenses incurred to the effective date of termination.
B. This Agreement may be suspended or terminated by CITY upon five (5) days'
written notice for violation by SUBRECIPIENT of Federal Laws governing the use of Community
Development Block Grant Funds. In the event of such suspension or termination, SUBRECIPIENT
shall only be entitled to reimbursement for approved expenses incurred up to the effective date of
suspension or termination.
C. Pursuant to 24 CFR 85.43, in the event SUBRECIPIENT defaults by failing to fulfill
all or any of its obligations hereunder, CITY may declare a default and termination of this
Agreement by written notice to SUBRECIPIENT, which default and termination shall be effective
on a date stated in the notice which is to be not less than ten (10) days after certified mailing or
personal service of such notice, unless such default is cured before the effective date of termination
stated in such notice. If terminated for cause, CITY shall be relieved of further liability or
responsibility under this Agreement, or as a result of the termination thereof, including the payment
of money, except for payment for approved expenses incurred for services satisfactorily and timely
performed prior to the mailing or service of the notice of termination, and except for reimbursement
of (1) any payments made for services not subsequently performed in a timely and satisfactory
manner, and (2) costs incurred by CITY in obtaining substitute performance.
D. The grant of funds under this Agreement may be terminated for convenience in
accordance with 24 CFR 85.44.
E. The grant of funds under this Agreement may be terminated due to the non-
performance of SUBRECIPIENT and/or failure of SUBRECIPENT to perform the work described
in Exhibits A and B or failure to meet the performance standards and program goals set forth
therein.
F. In the event this Agreement is terminated as set forth in subparagraphs XII.A.
through XII.E., inclusive, SUBRECIPIENT agrees to immediately return to CITY upon CITY's
demand and prior to any adjudication of SUBRECIPIENT's rights, any and all funds not used, and
to comply with paragraph "XI. REVERSION OF ASSETS" of this Agreement.
XIII. LIMITATION OF FUNDS
The United States of America, through HUD, may in the future place programmatic or fiscal
limitations on the use of CDBG funds which limitations are not presently anticipated. Accordingly,
CITY reserves the right to revise this Agreement in order to take account of actions affecting HUD
program funding. In the event of funding reduction, CITY may, in its sole and absolute discretion,
reduce the budget of this Agreement as a whole or as to costs category, may limit the rate of
SUBRECIPIENT's authority to commit and spend funds, or may restrict SUBRECIPIENT's use of
both its uncommitted and its unspent funds. Where HUD has directed or requested CITY to
implement a reduction in funding, in whole or as to a cost category, with respect to funding for this
13
8/04
Agreement, CITY's City Manager or delegate is authorized to act for CITY in implementing and
effecting such a reduction and in revising, modifying, or amending the Agreement for such
purposes. If such a reduction in funding occurs, SUBRECIPIENT shall be permitted to de -scope
accordingly. Where CITY has reasonable grounds to question SUBRECIPIENT's fiscal
accountability, financial soundness, or compliance with this Agreement, CITY may suspend the
operation of this Agreement for up to sixty (60) days upon five (5) days written notice to
SUBRECIPIENT of its intention to so act, pending an audit or other resolution of such questions.
In no event, however, shall any revisions made by CITY affect expenditures and legally binding
commitments made by SUBRECIPIENT before it received notice of such revision, provided that
such amounts have been committed in good faith and are otherwise allowable and that such
commitments are consistent with HUD cash withdrawal guidelines.
XIV. EXCLUSIVITY AND AMENDMENT OF AGREEMENT
This Agreement supersedes any and all other agreements, either oral or in writing, between
the parties hereto with respect to the use of CITY's CDBG funds by SUBRECIPIENT and contains
all the covenants and agreements between the parties with respect to such employment in any
manner whatsoever. 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, and that no other agreement or
amendment hereto shall be effective unless executed in writing and signed by both CITY and
SUBRECIPIENT.
XV. LAWS GOVERNING THIS AGREEMENT
This Agreement shall be governed by and construed in accordance with the laws of the State
of California, and all applicable federal laws and regulations.
XVI. VALIDITY
The invalidity in whole or in part of any provision of this Agreement shall not void or affect
the validity of any other provision of this Agreement.
XVII. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below 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 and Attachments referenced herein and attached hereto shall be
incorporated as if fully set forth in the body of this Agreement.
14
8/04
c. No delay or omission by either party hereto to exercise any right or power accruing
upon any noncompliance or default by the other party with respect to any of the terms of this
Agreement shall impair any such right or power or be construed to be a waiver thereof. A
waiver by either of the parties hereto of any of the covenants, conditions, or agreements to be
performed by the other shall not be construed to be a waiver of any succeeding breach thereof
or of any other covenant, condition or agreement herein contained.
15
8/04
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and
year written below.
DATED:
ATTEST:
PJ
�PATRICIA E. HEALY
Clerk of the Council
DATE:
16
CITY OF SANTA ANA
4��L'1 --
DAVID N. REAM
City Manager
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
By: LISA E. STORCK
Assistant City Attorney
SUBRECIPIENT:
Name: W.D. Chrisner 111
Title: Executive Director
director
Tax ID: 95-3313707
EXHIBIT A
Scope of Work
Annual Accomplishment Goal
1. Total number of clients anticipated to serve during the 12 -month contract period — 1800
11. Number of unduplicated Santa Ana residents to be served with grant funds during the 12 -month contract period
60 PERSONS 3% Santa Ana clients
I1. Description of Work - in space below, describe the program to be funded during the 12 -month contract period
including, services to be provided, program goals, client characteristics, & how grant funds will be utilized.
With Santa Ana CDBG funds, the Dayle McIntosh Center (DMC) will establish a program for the
purpose of offering employment services to persons with severe disabilities, who reside in Santa Ana. The
components of the proposed program will include employment preparation, job development and placement,
and post -placement follow-up assistance.
Seven out of ten people with disabilities are unemployed. In a Harris poll conducted in the mid
1990's, sixty-six percent of the respondents, all with disabilities, stated that they wanted to work. Two
countywide needs assessments commissioned by DMC in 1987 and 1997 revealed the same results: area
residents require help to secure employment. This input prompted DMC to adopt the goal of undertaking
activities to "advance the employment of people with disabilities" in DMC's current strategic plan.
Gainful employment is the cornerstone of independence for most people and individuals with
disabilities are no exception. In 2000, DMC established a program to facilitate economic self-sufficiency
through job placement. Community Development Block Grant funds are being requested to make this
program available directly to Santa Ana residents. The goals of the proposed project are:
To identify Santa Ana residents with disabilities, who seek employment.
To equip participants with the skills and resources to conduct an effective job search.
To facilitate job opportunities for people with disabilities.
To enhance job retention.
Sckedrde of Performance
Estimate the number of unduplicated Santa Ana residents to be served during the 12 -month contract period per
quarter:
Quarter 1: July 1 — September 30
Quarter 2: October 1 — December 31
Ouarter 3: January I -- March 31
Quarter 4: April I —June 30
Invoicing Schedule
15
Persons
15
Persons
15
Persons
15
Persons
Total 60
persons
stimate the amount of grant funds to be requested during the 12 -month contract period on
Quarter 1:
July I — September 30
S
3.750
Quarter 2:
October 1 —December 31
$
3.750
Quarter 3:
January I -- March 31
$
3,7 0
Quarter 4:
April 1 —June 30
$
3.750
Total $
15,000
EXHIBIT A
a quarterly basis:
Attachment 4(a)
PROGRAM YEAR 2004-2005
PUBLIC SERVICE PROGRAM BUDGET PROPOSAL
Organization Name: The Dayle McIntosh Center For The Disabled
Program Name: Bridges To Stability (New Program)
EXPENDITURES
CATEGORY
SANTA ANA CDBG
OTHER
TOTAL PROGRAM
Department of Rehabilitation — Case Services
GRANT REQUESTED
RESOURCES
BUDGET
Administrative Staff
Salaries & Benefits
$0
$7,260
$7,260
Program Staff Salaries &
Benefits
$15,00
45,000
60,000
Office Supplies
0
300
300
Rent/Lease
0
0
0
Communications
0
600
600
Utilities
0
0
0
Contractual/Professional
Services
0
0
0
Please Specify)
Insurance
0
200
200
Other (Please Specify)
1. Mileage
0
800
800
2. Disability
Accommodation
500
500
0
3. Printing/Postage
400
400
0
TOTAL
$15,000
$55,060
$70,060
PROGRAM RESOURCES
SOURCE
AMOUNT
Department of Rehabilitation — Fee for Service
$30,000
Department of Rehabilitation — Case Services
$25,060
TOTAL
$55,060
EXHIBIT B
Attachment 6
CDBG FUNDED PERSONNEL
ADMINISTRATIVE STAFF
CDBG
Total Funds
Position Title Annual Salary Annual Compensation Requested
Benefits
% of Time
Position is
Dedicated to
Program
Job Developer 49,586 10,413 60,000 15,000
50%
PROGRAM STAFF
CDBG
Total Funds
Position Title Annual Salary Annual Compensation Requested
Benefits
% of Time
Position is
Dedicated to
Program
Job Developer 49,586 10,413 60,000 15,000
50%
CONTRACT PERSONNEL
Position Title
CDBG % of Time
Total Funds Position is
Annual Salary Annual Compensation Requested Dedicated to
Benefits Program
15
8/04
Certification Regarding Lobbying
Certification for Contracts Grants Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the making of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of
any Federal contact, grant, loan or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form -LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontract, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by Section 1352, Title 31, U. S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than $10,000 and not more than $100,000 for each such failure.
Grantee/Contactor Organization
Program Title
Name of Certifying Officer Signature Date
EXHIBIT C
Page 1 of 2
17
8/04
SUBRECIPIENT warrants the following
1. SUBRECIPIENT will comply with Public Law 88-352, Title VI of the Civil Rights Act of
1964 (42 U. S. C. section 2000 et seq.) and implementing regulation in 24 CFR Part 1.
2. No person in the United States shall on the ground of race, color, religion, national origin, or
sex, be excluded from participation in, or be denied the benefits of, or be subjected to
discrimination under any program or activity funded in whole or in part with community
development funds made available pursuant to the ACT.
3. All laborers and mechanics, employed by contractors or subcontractors in the performance of
construction work financed in whole or in part with community development funds shall be paid
wages at rates not less than those prevailing on similar construction in the locality as determined
in accordance with the Davis -Bacon Act, as amended, 40 U. S. C. Sections 276 a 1-5, except for
individuals who perform services for which they volunteered; do not receive compensation for
such services; or are paid expenses, reasonable benefits, or a nominal fee for such services; and
are not otherwise employed at any time in construction work.
4. SUBRECIPIENT will comply with all Federal statutes applicable to projects funded with
community development funds, except that (a) SUBRECIPIENT does not assume CITY'S
environmental responsibilities described at 24 CFR 570.604; and (b) SUBRECIPIENT does not
assume CITY'S responsibility for initiating the review process under Executive Order 12372.
EXHIBIT C
Page 2 of 2
IM
ACORv CERTIFICAT- OF
!ABILITY INSURAW l OP ID J DATE(MWDDNYYY)
1E
PRODUCER -
Chapman & Associates
License #0522024
P. O. Box 5455
Pasadena CA 91117-04$5
, DAY 1- 05/28/04
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Phone: 626-405-8031 Pax:626-405-0585
INSURERS AFFORDING COVERAGE NAIC#
INSURED
DATE M
INSURER A: iiveryorc ivaurane� Cevpany
INSURER B:
X
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLA7AS MAGE X❑OCCUR
X Professional Llab
Dayle McIntosh Center
13272 Garden Grove Bl.
Garden Grove CA 92843
05/25/04
INSURER C'
INSURER D:
INSURER E:
PREMISES Ea occurence)
E $0000
r-nVFRAGFS:
$5000
PERSONAL S ADV INJURY
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTRWnI
TYPE bF INSURANCE
POLICY NUMBER
DATE MMID
DATE M
LIMITS
A
X
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLA7AS MAGE X❑OCCUR
X Professional Llab
RP0004983
05/25/04
05/2$/0$
EACH OCCURRENCE
$lOOOOOO
PREMISES Ea occurence)
E $0000
MED EXP (Any one Person)
$5000
PERSONAL S ADV INJURY
$1000000
GENERAL AGGREGATE
$ 3000000
GENL AGGREGATE LIMIT APPLIES PER:
POLICY PRO -
JECT Loc
PRODUCTS -COMWOP ADD
$ 3000000
Ben.
INCLUDED
AUTOMOBILE
LIABILITY
A
X
ANY AUTO
RP0004983
05/25/04
05/25/05
COMBINED SINGLE LIMIT
(Ea acddenl)
$lOOOOOO
ALL OWNED AUTOS
SCHEDULEDAUTOS
BODILY INJURY
(Per person)
E
X
HIRED AUTOS
X
NON -OWNED AUTOS
BODILY INJURY
(Per accident)
E
PROPERTY DAMAGE
(Per accident)
E
'
GARAGE L"ILITY
AUTO
E-
!ACCIDENT
OTHER THAN EA ACC
AUTO ONLY: ADD
E
f
ACLAIMSMADE
t�CESSAJMBREL�nLIABIIJTY
RPX004984
0$/25/03
0$/2$/04
EACH OCCURRENCE
$lOOOOOO
AGGREGATE
$1000000
E
$10000
E
COMPENSATION AND
EMPLOYWORKERS
EMPLOYERS' LIABILITY
TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTNE
OFFICERIMEMBER EXCLUDED?
E.L. EACH ACCIDENT
E
Ryes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - EA EMPLOYE
$
OTHER
E. L. DISEASE - POLICY LIMB
$
A Sexual Abuse Liab RP0004983 05/25/04 05/25/05
Ins Limit
Included
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BV ENDORSEMENT I SPECIAL PROVISIONS
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 with respect to the operations of the named insured.
CERTIFICATE HOLDER
SANTAA4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
City of Santa Ana NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Community Development Agency IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P.O. BOX 1988 REPRESENTATIVES.
Santa Ana CA 92702-1988 AUT EO REPRES ATIVE
25 (2001/08)
(C) ACORD CORPORATION 1988
Q
RIVERPORT INSURANCE COMPANY OF CALIFORNIA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY BROADENING ENDORSEMENT
This endorsement modifies the insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Throughout this endorsement the words "you" and "your" refer to the Named Insured shown in the Declarations. The word "we,"
"us" and "our" refer to the Company providing this insurance.
The following is only a sunmtary of the additional coverages providedby Us endorsement and is provided only for your reference
and convenience. For the Limits of Insurance and the additional coverages provided by this endorsement, read the provisions on
the following pages and the Coverage Foran which this endorsement modifies.
SUBJECTS OF INSURANCE
Broadened Bodily Injury
Broadened Personal and Advertising Injury
Broadened Property Damage -
Broadened Fire, Lightning, Explosion & Sprinkler Leakage - $500,000
Broadened Medical Payments - $10,000
Broadened Supplementary Benefits
a. Bail Bonds - $1,000
b. Expenses Incurred to Assist in Defense - $500 per Day f�(
Broadened Newly -Acquired or Formed Organization
Broadened Non -Owned or Chartered Watercraft or Aircraft
Broadened Commercial General Liability Conditions -
a. Duties in the Event of Occurrence, Offense, Claim or Suit _
b. Liberalization B Automatic Coverage If We Adopt Broader Coverages
c. Notice to Company
Automatic Coverage for "Special Events"--
Automatic Additional Insureds
a. Athletic Activity Participants
& Contractual Obligations
c. Funding Sources
d. Manager or Lessor of Premises
e. Owner, Manager, Operator or Lessor of "Special Event' Premises _
f. Supervisors or Higher in Rank B Co -Employee Exclusion Removed
g. Volunteer Workers
It. Limitations
Blanket Waiver of Subrogation
Priority of Application for Multiple Insureds
The coverages listed in this endorsement are provided as extensions or additions to your insurance program
HSCG 00 010700 Inetada copyrighted materia! of Page I of 9
Insurance Services Vices:, with its permission
1. BROADENED BODILY INJURY
SECTION V - DEFINITIONS, Item 3. is replaced
with:
3. "Bodily injury" means physical injury, sickness,
or disease sustained by a person, including
death resulting from any of these. "Bodily
injury" also means mental injury, mental
anguish, humiliation or shock sustained by a
person, if directly resulting from physical
injury, sickness or disease sustained by that
person.
2. BROADENED PERSONAL AND
ADVERTISING INJURY
SECTION V - DEFINITIONS, Item 14. is replaced
with:
14. "Personal and Advertising Injury" means injury,
including consequential "bodily injury" arising
out of one or more of the following offenses
during the policy period:
a. False arrest, detention or imprisonment;
b. Malicious prosecution or abuse of process;
c. The wrongful eviction from, wrongful
entry into, or invasion of the right of
private occupancy of a room, dwelling or
premises that a person occupies by or on
behalf of its owner, landlord or lessor,
d. Oral, written, televised, videotaped or
electronic publication of material that
slanders or libels a person or organization
or disparages a person=s or
organization=s goods, productsor
services;
e_ Oral, written, televised, videotaped or
electronic publication of material that
violates a person=s right of privacy or
L Misappropriation of advertising ideas or
style of doing business; or
g. Infringement of copyright, title or slogan.
h. Mental injury, mental anguish, humiliation
or shock, if directly resulting from hems
14.a, through 14.g. above.
LIABILITY EXCLUSIONS, Paragraphs 2.a.(2) and
2.a.(3) are replaced with:
(2) Arising out of oral, written, televised,
videotaped or electronic publication of
material, if done by or at the direction of the
insured with knowledge of its falsity;
(3) Arising out of oral, written, televised,
videotaped or electronic publication of
material whose fust publication took place
before the beginning of the policy period;
4. BROADENED PROPERTY DAMAGE
SECTION I - COVERAGES, COVERAGE A.
BODILY INJURY AND PROPERTY DAMAGE
LIABILITY EXCLUSIONS, Paragraph 2.a. is
replaced with:
a. "Bodily injury" or "property damage"
expected or intended from the standpoint of
the insured. This exclusion does not apply to
"bodily injury" or "property damage"
resulting from the use of reasonable force to
protect persons or property.
5. BROADENED FIRE, LIGHTNING, EXPLOSION
AND SPRINKLER LEAKAGE
A. SECTION III - LIMITS OF INSURANCE,
Paragraph 6. is replaced with:
6. Subject to 5. above, the Damage to Premises
Rented to You Limit is the most we will pay
under Coverage A for damages because of
"property damage" to:
a. Anyone premises while rented to you or
temporarily occupied by you with
permission of the owner; or
b. Personal property of others in your care,
custody or control, while at premises
rented to you or temporarily occupied by
you with permission of the owner
arising out of any one fire, lightning,
explosion or sprinkler leakage occurrence.
In the case of fire, the Fire Damage Limit is
the greater of:
a. $500,000; or
b. The amount shown in the Declarations
for Fire Damage Limit.
SECTION 1 - COVERAGES, COVERAGE B. B. The last paragraph of SECTION I -
PERSONAL AND ADVERTISING INJURY COVERAGES, COVERAGE A. BODILY
INJURY AND PROPERTY DAMAGE
BSCG 00 0107 00 Includes copyrighted material of Page 2 of 9
Insurance Semites Ofcee, with Aspennission
LIABILITY, Paragraph 2. Exclusions is
replaced with:
Exclusions e. through n. do not apply to damage
by fire, lightning, explosion or sprinkler leakage
to premises while rented to you or temporarily
occupied by you with permission of the owner.
A separate limit of insurance applies to this
coverage as described in LIMITS OF
INSURANCE (Section III).
C. SECTION IV -COMMERCIAL GENERAL
LIABILITY CONDITIONS, Paragraph 4.
Other Insurance, Item b.(1)(b) is replaced
with:
(b) That is Fire, Lightning, Explosion or
Sprinkler Leakage insurance for
premises rented to you or temporarily
occupied by you with permission ofthe
owner; or
D. SECTION V - DEFINITIONS, Item 9.a. is
replaced with:
a. A contract for a lease of premises.
However, that portion of the contract for a
lease of premises that indemnifies any
person or organization for damage by fire,
lightning, explosion or sprinkler leakage to
premises while rented to you or temporarily
occupied by you with permission of the
owner is not an "insured contract";
E. This Broadened Coverage is subject to all the
terms of SECTION IH - LUMTS OF
INSURANCE.
F. 'Ibis Broadened Coverage does not apply if Fre
Damage Liability of COVERAGE A
(SECTION 1) is excluded either by the
Declaration to this Coverage Part or by an
endorsement to this Coverage Part.
6. BROADENED MEDICAL PAYMENTS
A. The following provision is added to Paragraph 7.
of SECTION III — LIMITS OF
INSURANCE:
The Medical Expense Limit shall be the greater
of:
b. $10,000;or
b. The amount shown in the Declarations for
Medical Expense Limit.
C. This above Medical Expense Lunit does not apply
if COVERAGE C. MEDICAL PAYMENTS is
excluded either by the Declaration to this
Coverage Part or by an endorsement to this
Coverage Part.
7. BROADENED SUPPLEMENTARYPAYMENTS
Under SECTION I - SUPPLEMENTARY
PAYMENTS - COVERAGES A AND B,
Paragraphs 1.(b) and 1.(d) are replaced with:
b. Up to $1,000 for cost of bail bonds required
because of accidents or traffic law violations
arising out of the use of any vehicle to which
the Bodily Injury Liability Coverage applies.
We do not have to famish these bonds.
d. All reasonable expenses incurred by the
insured at our request to assist us in the
investigation or defense of the claim or
"suit," including actual loss of earnings up to
$500 a day because of time off from work.
8. BROADENED NEWLY ACQUIRED OR
FORMED ORGANIZATION
A. SECTION H - WHO IS AN INSURED, Item
4.2. is replaced with:
a. Coverage under this provision is afforded
only until the 120th day after you acquire or
form the organization or the end of the policy
period, whichever is earlier.
9. BROADENED NON -OWNED OR CHARTERED
WATERCRAFT OR AIRCRAFT
SECTION I - COVERAGES, COVERAGE A.
BODILY INJURY AND PROPERTY DAMAGE
LIABILITY, Paragraph 2.g. is replaced with:
g. "Bodily injury" or "property damage" arising
out of the ownership, maintenance, use or
entrustment to others of any aircraft, "auto"
or watercraft owned or operated by, or rented
or loaned to, any insured. Use includes
operation and "loading or unloading".
This exclusion does not apply to:
(1) A watercraft while ashore on premises
you own or rent;
(2) A watercraft you do not own that is:
(a) Less than 51 feet long; and
B. This Medical Expense Limit is subject to all the (b) Not being used to carry persons or
terms of SECTION III - LU43TS OF property for a charge;
INSURANCE.
(3) Parking an "auto" on, or on the ways
next to premises you own or rent,
provided the "auto" is not owned by or
HSCG 00 0107 00 Includes copyrighted material of Page 3 of 9
Insurance service O)Tlcm, with its permission
rented or loaned to you or the insured;
(4) Liability assumed under any
"insured
(5) contract® for the ownership,
maintenance or use of watercraft
or aircraft; or
(5) "Bodily injury" or "property damage"
arising out of the operation of any of
the equipment listed in paragraph f.(2)
or f.(3) of SECTION V -
DEFINITIONS, Paragraph 11.,
"Mobile Equipment"; or
(6) An aircraft you do not own that is:
(a) Hired, chartered or loaned with a
crew; and
(b) Not owned in whole or in part by
any insured.
('n This insurance does not apply, under
paragraph 9.(1) and g.(2) above, if the
insured has any other insurance for
"bodily injury" or "property damage"
which would also apply to loss covered
under this provision, whether the other
insurance is primary, excess, contingent
or on any other basis.
(8) This insurance is excess, under
paragraph g.(6) above, over any other
insurance, whether the other insurance
is primary, excess, contingent or on any
other basis.
10. BROADENED COMMERCIAL GENERAL
LIABILITY CONDITIONS
A. SECTION IV - COMMERCIAL GENERAL
LIABILITY CONDITIONS, Paragraph 2.
Duties In The Event Of Occurrence, Offense,
Claim Or Suit is amended to add the following
provision:
e. Your obligation to notify us as soon as
practicable of an "occurrence," or offense
under paragraph 2.2. above, or a claim or
"suit " or offense under paragraphs 2.a,
2.b, and 2.c, above, is satisfied if you send
us written notice as soon as practicable after
any of your "executive officers,® directors,
partners, insurance managers, or legal
representatives becomes aware of, or should
have become aware of, such "occurrence,"
offense, claim or "suit."
10. Liberalization.
If we adopt any revision that would broaden
the coverage under this coverage part without
additional premium within 30 days prior to or
during the policy period, the broadened
coverage will immediately apply to this
coverage part.
11. Notice To Company
If you report an "occurrence" or offense to
your Workers= Compensation insurer which
later becomes a claim under this Coverage
Part, failure to report such "occurrence" or
offense to us at the time of the "occurrence"
or offense will not be considered a violation
of the Duties In The Event Of Occurrence,
Offense, Claim Or Suit Condition, if you
notify us as soon as practicable when you
become aware that the "occurrence" or
offense has become a liability claim
11. AUTOMATIC COVERAGE FOR ASPECIAL
EVENTS.a
A. You are automatically covered for all "special
events" whichyou organize, promote, administer,
sponsor, or conduct during the term of this policy.
B. SECTION V - DEFINr170NS, is amended to
add the following paragraph:
22. "Special Event" means any event:
a. The purpose of which is to raise funds
for you; or
b. To recognize the accomplishments of
your organization, your employees," or
your volunteer workers; or
C. Which you, or an individual or
organization with whom you have
entered into a contract or agreement,
organize, promote, administer, sponsor
or conduct for the purposes described in
paragraphs a. orb. above; and
d. Which takes place on premises owned
by you, or on premises while rented or
leased to you, or to that organization
described in paragraph c. above.
e- However, "special event' shall NOT
include, and no insurance is afforded
under this Coverage Part, for:
(1) any event at which you, your
B. The following provisions we added to "employees," or your volunteer
SECTION IV - COMMERCL4L GENERAL workers sell alcoholic beverages or
LIABILITY CONDITIONS: sell tickets or coupons which may
be exchanged for alcoholic
beverages; or
HSCG 00 0107 00 Includes copyrighted material of Page 4 of 9
insurance Swices OVIces., with its permission
(2) any event which involves:
(a) professional or semi-
professional athletic teams;
(b) fairs, rodeos, carnivals,
haunted houses, or street
parties;
(c) pyrotechnic displays;
(d) racing or timed events of all
kinds, including but not
limited to, automobile or
watercraft racing, airplane
racing or exhibitions, soap-
box derbies, bike-a-thons,
marathons, and walkathons;
or
(e) race tracks or stadiums
operated by you.
Coverage for the "special events" listed
under e.(1) and e.(2) above shall be
extended only by a specific endorsement
issued by us.
12. The following provisions are added to SECTION H
- WHO IS AN INSURED.
5. Automatic Additional Insured(s)
a. Additional Iusureds - Athletic Activity
Participants
(1) This policy is amended to include as an
insured any persons) (hereinafter
called Additional Insured(s)
representing you while participating in
amateur athletic activities that you
sponsor. However, no such person is
an insured for:
(a) "Medical expenses" under
COVERAGE C. MEDICAL
PAYMENTS.
(b) "Bodily Injury" to:
(i) a co -participant, your
volunteer worker or your
"employee" while
participating in amateur
athletic activities that you
sponsor, or
owned by, occupied or used by,
rented to, in the care, custody, or
control of, or over which physical
control is being exercised for any
purpose by:
(i) aco-participant, your volunteer
worker, or your "employee;®
or
(ii) you, or any partner or member,
(if you are a partnership or
joint venture), or any member
(if you are a limited liability
company).
b. Additional Insured - Contractual
Obligations
(1) This policy is amended to include as an
insured any person or organization
(hereinafter called Additional Insured)
that you are required by a written
"insured contract" to include as an
insured, subject to all of the following
provisions:
(a) Coverage is limited to liability
arising out of:
(1) your ongoing operations
performed for such Additional
Insured; or
(ii) such Additional Insured's
financial control of you; or
(iii) the maintenance, operation or
use by you of equipment leased
to you by such Additional
Insured; or
(iv) a permit issued to you by a
state or political subdivision.
(b) Coverage does not apply to any
"occurrence" or offense:
(i) which took place before the
execution of, or subsequent to
the completion or expiration
of, the written "insured
contract," or
(ft) which takes place after you
cease to be a tenant in that
premises.
(ii) you, or any partner or
member, (if you are a (c) With respect to architects,
partnership or joint venture), engineers, or surveyors, coverage
or any member (if you me a does not apply to `Bodily Injury,"
- limited liability company); or "Property Damage," "Personal
Injury," or "Advertising Injury"
(c) 'Property damage" to property arising out of the rendering or the
HSCG 00 01 07 00 lnrludes rnpyrigkted material-=, Page 5 of 9
lnsuraaeeservices ofcex, with itspermission
failure to render any professional
than that customarily provided by
services by or for you including:
the policy forms specified in and
required by the contract.
(i) the preparing, approving, or
failing to approve or prepare
(e) In no event shall the coverages or
maps, drawings, opinions,
Limits of Insurance in this
reports, surveys, change
Coverage Form be increased by
orders, designs or
such contract.
specifications; and
(d) Coverage provided herein shall be
(it) supervisory, inspection, or
considered excess over any other
engineering services.
valid and collectible insurance
available to the Additional Insured
(d) Coverage provided herein shall be
whether that other insurance is
considered excess over any other
primary, excess, contingent, or on
valid and collectible insurmice
any other basis unless a written
I available to the Additional Insured
contractual arrangement specifically
whether that other insurance is
requires this insurance to be
primary, excess, contingent, or on
primary.
any other basis unless a written
contractual arrangement
d. Additional Insured -Manager or Lessor of
specifically requires this insurance
Premises
to be primary.
(1) This policy is amended to include as an
(e) In the event that you are engaged
insured any person or organization
in the manufacture or assembly of
(hereinafter called Additional Insured)
any goods or products for the
from whom you lease or rent your
benefit or at the direction of
premises and which requires you to add
another party, pursuant to a
such person or organization as an
contract or agreement with that
Additional Insured in this policy under:
party, this paragraph (d.) does not
extend coverage tothat party as an
(a) A written contract; or
Additional Insured. Coverage for
such a party will be extended only
(b) An oral agreement or contract
by a specific endorsement issued
where a Certificate of Insurance has
by us and naming such party.
been issued showing that person or
organization as an Additional
c. Additional Insured - Funding Sources
Insured;
(1) This policy is amended to include as an
but only if the written or oral agreement
insured any Funding Source
is an "insured contract,®
(hereinafter called Additional Insured)
which requires you in a written contract
(i) currently in effect or to become
-. to name such Additional Insured but
effective
only with respect to liability arising out
policy; and
of your premises or "your work" for
such Additional Insured, and only to
(it) executed prior to the 'bodily
the extent set forth as follows:
injury,® "property damage,"
-
"personal injury" or
(a) The Limits of Insurance applicable
"advertising injury."
to the Additional Insured are the
-
lesser of those specified in the
(2) With respect to the insurance afforded
written contract or agreement or in
the Additional Insured identified in
_ the Declarations for this policy and
paragraph d.(1) immediately above, the
subject to all the terms, conditions
following additional provisions apply:
and exclusions is policy. The
Limits of Insurance applicableto
(a) This insurance applies only to
the Additional Insured are
liability arising out of the
inclusive of, and not in addition to,
ownership, maintenance or use of
the Limits of Insurance shown in
that portion of the premises leased
the Declarations.
to you;
(b) The coverage provided to the (b) The Limits of Insurance applicable
Additional Insured is not greater to the Additional Insured are the
HSCG 00 0107 00 Includes copyrighted material of Page 6 of 9
Insurance Services Offices, with its permission
lesser of those specified in the
written contract or agreement or in
the Declarations for this policy and
subject to all this policy's terms,
conditions and exclusions. The
Limits of Insurance applicable to
the Additional Insured are
inclusive of, not in addition to, the
Limits of Insurance shown in the
Declarations.
(c) In no event shall the coverages or
Limits of Insurance in this
Coverage Part be increased by
such contract or agreement.
(d) Coverage provided herein shall be
considered excess over any other
valid and collectible insurance
available to the Additional Insured
whether that other insurance is
primary, excess, contingent, or on
any other basis unless a written
contractual arrangement
specifically requires this insurance
to be primary.
(3) This insurance does not apply to:
(a) Any "occurrence" or offense
which takes place after you cease
to be a tenant in the premises
covered by this endorsement; or
(h) Stmctural alterations, new
construction or demolition
operations performed by or on
behalf of the Additional Insured_
e. Additional Insured - Owner, Manager,
Operator or Lessor of "Special Events"
Premises
(1) This policy is amended to include as an
insured any person or organization
(hereinafter called Additional Insured)
from whom you lease, rent or occupy
the premises upon which a "special
event" is held, sponsored or conducted
by you, or on your behalf, under:
(a) A written contract; or
(b) An oral agreement or contract
where a Certificate of Insurance
has been issued showing that
person or organization as an
Additional Insured;
but only if the written or oral
agreement is an "insured contract,"
(t) currently in effect or to
become effective during the
terrn of this policy; and
(ii) executed prior to the "bodily
injury," "property damage,"
"personal injury," or
"advertising injury."
(2) With respect to the insurance afforded
the Additional Insured identified in
paragraph e.(1) of this endorsement, the
following additional provisions apply.
(a) This insurance applies only to
liability arising out of the use of that
portion of the premises while leased
or rented to you for the specific
"special event;"
(b) The Limits of Insurance applicable
to the Additional Insured are the
lesser of those specified in the
contract or agreement pertaining to
the use of the premises or in the
Declarations for this policy and
subject to all of this policy=s terms,
conditions and exclusions. The
Limits of Insurance applicable to
the Additional Insured are inclusive
of, not in addition to, the Limits of
Insurance shown in the
Declarations.
(e) In no event shall the coverage or
Limits of Insurance in this
Coverage Form be increased by
such contract or agreement.
(d) Coverage provided herein shall be
considered excess over any other
valid and collectible insurance
available to the Additional Insured
whether that other insurance is
primary, excess, contingent, or on
any other basis unless a written
contractual arrangement specifically
requires this insurance to be
primary.
(3) This insurance does not apply to:
(a) Any `occurrence" or offense which
takes place after you cease to be a
tenant, licensee or occupant in the
premises covered by this
endorsement; or
(b) Any acts or "occurrences" caused
by or attributable to the owner,
manager, operator or lessor of the
premises upon which the "special
event" is held.
L Additional Insureds - Supervisors or
Higher in Rank
HSCG 00 01 07 00 Includes copyrighted material of Page 7 of 9
InsuranceServices Ofces., with its pennfssion
(1) This policy is amended to include as an
physical control is being
insured any "employees" (hereinafter
exercised for any purpose by
called Additional Insured), designated
as supervisor or higher in tank, who are
you, any of your "employees,®any
authorized by you to exercise direct or
partner or member (if you are a
indirect supervision and control over
partnership or joint venture), or any
"employees" and the manner in which
member (if you are a limited
work is performed, but only for acts
liability company).
within the scope of their employment
by you or while perfornang duties
(2) SECTION II - WHO IS AN
related to the conduct ofyour business.
INSURED, Paragraph 3.a. is deleted.
However, none of these "employees"
designated as supervisor or higher in
g. Additional Insureds- Volunteer Workers
rank, is an insured for:
(1) This policy is amended to include as an
(a) 'Bodily injury" or "personal
insured any persons (hereinafter called
injury":
Additional Insured) who are volunteer
workers for you, but only while acting at
(i) to you, to your partners or
your direction, and within the scope of
members (if you are a
the duties which they perform for you.
partnership or joint venture),
However, none of these volunteer
or to your members (if you
workers are insured for:
are a limited liability
company);
(a) 'Bodily injury" or "personal
injury":
(if) for which there is any
obligation to share damages
(i) to you, to your partners or
with or repay someone else
members (if you are a
who must pay damages
partnership orjoint venture), to
because of the injury
your members (if you are a
described in paragraph (a)(i)
limited liability company), to
- above; or
your other volunteer workers,
or to your "employees" arising
(fit)arising out of his or her
out of and in the course of their
providing or failing to provide
duties for you;
professional health care
services.
(ii) to the spouse, child, parent,
brother or sister of your
(b) 'Personal Injury":
volunteer worker(s) or your
"employees" as a consequence
(i) to a co -"employee" while in
of paragraph (a)(i) above; or
the course of his or her
employment, or
(iii) for which there is any
obligation to share damages
(if) to the spouse, child, parent,
with or repay someone else
brother or sister of that co-
who must pay damages
"employee" as a consequence
because of the injury described
of paragraph (b)(f) above;
in paragraphs (a)(i) or (i)
above; or
(fit) for which there is any
obligation to share damages
(iv) arising out of the volunteer
with or repay someone else
worker(s) providing or failing
who must pay damages
to provide professional health
because of the injury
care services.
described in paragraph (b)()
or (if) above.
(b) "Property damage" to property:
(c) 'Property damage" to property:
(i) owned, occupied or used by;
(i) owned, occupied or used by;
(if) rented to, in the care, custody,
or
or control of, or over which
-
physical control is being
(if) rented to, in the cue, custody
exercised for any purpose by;
or control of, or over which
HSCG 00 0107 00 Includes copyrighted material of Page 8 of 9
lnsur"ce Services Offices., with its permission
you, any of your other volunteer
SECTION IV - COMMERCIAL GENERAL
worker(s),your "employees,®your
LIABILITY CONDITIONS, Item S. is replaced
partners or members (if you are a
partnership or joint venture), or
with:
8. Transfer of Rights Of Recovery Against
any member (if you are a limited
Others To Us And Blanket Waiver Of
liability company).
Subrogation
h. Additional Insureds - LIMITATIONS
a. If an insured has rights to recover all or part
of any payment we have made under this
(1) The persons, entities or organizations
to which coverage is extended under
Coverage Part, those rights are transferred to
us. The insured must do nothing after loss to
paragraphs a. (Athletic Activity
impair them At our request, the insured will
Participants), b. (Contractual
bring "suit" or transfer those rights to us and
Obligations), c. (Funding Sources), d.
help us enforce them
(Managers or Lessors ofPremises), and
e. (Owner, Manager, Operator or
b. If required by a written "insured contract,"
Lessor of "Special Events" Premises)
we waive any right of recovery we may have
are Additional Insureds, but only:
against any person or organizationbecause of
payments we make for injury or damage
(a) With respect to each Additional
arising out of your ongoing operations or
'your work" done under a contract for that
Insured=s vicarious liability for
"actual damages" solely caused by
person or organization and included in the
you or by "your work" that is
"products -completed operations hazard.@
ongoing for such Additional
Insured=s supervision of "your
14. PRIORITYOFAPPLICATIONFORMULTIPLE
work"; and
INSUREDS
(b) If the Additional Insured did not
SECTION III - LIMITS OF INSURANCE is
cause or contribute to the
amended to add the following paragraph:
"occurrence" or act resulting in
liability.
8. In the event a claim or "suit" is brought against
more than one insured, due to "bodily injury" or
(2) If an Endorsement is attached to this
"property damage" from the same "occurrence."
or "personal injury" or "advertising injury" from
policy and specifically names a person
or organization as an Additional
the same offense, we will apply the Limits of
Insured, then the coverage extended
Insurance in the following order:
under this paragraph S. AUTOMATIC
ADDITIONAL INSURED(S) does
a. You;
not apply to that person, entity or
b. Your "executive officers," directors,
organization.
"employees"; and
(3) SECTION V - DEFINITIONS, is
amended to add the following Item 23:
c. Any other insureds in any order that we
choose.
23. "Actual Damages" is to have its
usual and customary legal meaning
and excludes, without limitation,
Indamages, restitution,
penalties, and formula damages
added to "actual damages" and any
other enhanced damages.
(4) All other terms and conditions of this
Coverage Part which are not
inconsistent with this paragraph h.
apply to coverage extended to the
above -referenced Additional Insureds
REGARDLESS OF WHETHER OR
NOT A COPY OF THIS COVERAGE
PART AND/OR ITS
ENDORSEMENTS ARE
DELIVERED TO AN ADDITIONAL
INSURED.
13. BLANKET WAIVER OF SUBROGATION
HSCG 00 0107 00 Includes copyrighted material of Page 9 of 9
Insurance services Offices., with i[spermission
2c1,14 05 03:11p F k Family Ins If ;7722912 p,l
ACOB-D,N
CERTIFICATE OF LIABILITY
INSURANCE
ATE
06/13/2005 °
�wcec
Park Balmily
Inabranbe, Inc.
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORNWTION
ONLY COWERS NO RIGHTS UPON THE
"OLDERNTf" CERTIFICATE DONOT AMEND, CERTIFICATE
EXT'END OR
801 Riverside Ave #100
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW..
POLICY IXp��1TR�AAT ON
Roeaville -
cA 95678
"�—
WSURERB AFFORMO COVERAGE NAICA
NAl1R®
Nt9JRERA'.p1111ade1D & IneuYance Co
Dayle Mc Instomh
Center Sar The Disabled
_
13272 Gard o
Grove Blvd A-aooq-009-1(v
INSURER G. ..
_
INSUR urx•.... —-- --
05/25/2006
Garden Grove
CA 92843
INSURERS,
COVERAIlms
THE POLICIES OF INSURANCE LISTED BEUDW HAVE SEEN ISSUED TOTHE INSURED NANIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIAITHSTANDMIO ANY
REOXAREEENT, TERN OR COIAXTON OF ANY f7C11TTRACT OR OTHER DOCUMENT WITH RESPECT TO WITCH THIS CERTW-I ATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES OESORIBED HEREIN W SUBJECT TO ALL THE TERNS. EXCLUSICNS AND CONDITIONS OF SUCH POLIO7f9.
AGGREGA_ TE UAYTS SNOYNI MAY HAVE BEEN REDUCEfeY PNDCWMS. ... _.....!_.
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DESCRIPTION CF AOM BY DWORMMENTrwciAL RRDVLLUNE
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f`FQTCMeTc un, ..cn
SHOULD ANY OF THE AB W! O"ORIBED POIJOWS BE DANCRLED WORE THE
EXPIkATION DATE THMt , TME I JNO MMURER WILL MMAR
30 DAYS WRITTEN NOTICE TO THE CERTINGTE HOLDER NAe� TO THE L13Ta IIS/
City b£ Santa Ana
CPTIR9.TDity DE+velopweut
ESD Bax LBBB AUTNOR121Ep FEPREAENTA
Santa Ana CA 92702
ACORD M�(0pT x O ACORD CORPORATION IEEE ��•
'AIMS FI UCTRONIC LAEM WHMS. INC.
- (9DW737-0Tg5 P.J. 1 d1
a Rue Q4 05 04:07p Par
Holder Code:
Insured Name:
Policy Number:
Insure-:
City of Santa Ana
family Ing
Santa Ana
Dayle Mcintosh Center
PHPK122:?57
Pbiladelphia Insurance Co.
18F '722912
Page: 2
Date 6-1;-05
their respective officers, employees,
agents, volunteers and Representatives are named as additional insured with
regard to liability and defense of suits arising from the operations and uses
performed by or on behalf of the named insured, With respect to claims arising
out of the operations and uses performed by or on behalf of the name insured.
Such insurance as is afforded by this policy is primary and is not additional or
contributing with any other insurance carried by of for the benefit of the additional
insured.
This insurance applies separately to each insured against whom claim is made of
suit is brought except with respect to the organization's limits of liability. The
inclusion of any person or organization as an insured shall not affect any right
which such person of organization would have as a claimant if not so included.
Authorized Signature:
APPRO\'ci) AS TO FORM
h>,nla n: City Attorney
p.2
2d Wd0l:b0 S00z 7o '6nd 7602-299-7tL: 'ON XU:i aaquaO 45ojuIoW alhpQ' WOH-j
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SP
. THOLDER COPY
STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 04-01-2005 GROUP:
POLICY NUMBER: 0682897-2005
CERTIFICATE ID: 101
CERTIFICATE EXPIRES: 04-01-2006
04-01-2005/04-01-2006
CITY OF SANTA ANASP JOB:
COMMUNITY DEVELOPMENT AGENCY
PO BOX 1988
SANTA ANA CA 92702
This is to certify that we have issued a valid Workers'' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
.This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer.
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies .listed herein.' Notwithstanding any requirement, term, or condition of any contract or other document
with respect to which this certificate of insurance 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.
X"
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:. $1,000,000.00 PER OCCURRENCE.
ENDORSEMENT -#0015ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 04-01-2005 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2005 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
APPROVED As TO FORM
Laura Stiit'Sheedy
Assistant City Attorney ,
EMPLOYER
LEGAL NAME
DAYLE MC INTOSH CENTER
FOR THE DISABLED, INC
13272 GARDEN GROVE BLVD
GARDEN GROVE CA 92843
DAYLE MC INTOSH CENTER FOR THE DISABLED
INC. #2
(A NON-PROFIT CORP.)
(REV.3-03) PRINTED: 03/17/2005