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Home My WebLink AboutLE, CHOC 2ICity of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM ._ nrvl� 3' i Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. The agreement with Le, Choc ail f<1. COTC Office Use Only No. A-2004-122 (�2&)' was completed on 6/30/09 and final payment has been made. (List all amendments. Use space below if needed.) /p� Czf) (29) A-2005-149, A-2006-145, A-2004-122-03,011) ' Department: PRCSA f-A-2004-122-04,tA-2004-122-05 t2f) t2j) - Phone/Ext.: 5254 0-2000-(WbC2.) core '+A•2003.WC20 +N-2001-101Jc24)' 4A•2003-197 t N-ISO 2.-047 CZb)' Signature: S1A��(i� P��+imtly� Date: Revised 08-23-10 JSUW,v:i-bN FILE. 1' C CPIRES 1-7 C7 A-2004-122-04 D: Y9kCSW FOURTH AMENDMENT TO AGREEMENT THIS FOURTH AMENDMENT TO CONSULTANT AGREEMENT is entered into on April 19, 2007, by and between CHOC LE, a sole proprietor ("Consultant") and the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). RECITALS: A. The parties entered into Consultant Agreement A-2004-122, dated June 21, 2004, (hereinafter "said Agreement") by which Consultant has provided martial arts instruction for participants registered through the City's Parks, Recreation and Community Services Agency. B. In accordance with the terms and conditions of said Agreement, the parties wish to amend the Scope of Services to reflect the parties' understanding regarding the City's ability to reschedule classes when necessary. WHEREFORE, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this Fourth Amendment to Agreement, the parties agree as follows: 1. Section 2.a., COMPENSATION, shall be amended to increase compensation by $25,000 to pay for services during the 2007-2008 fiscal year. 2. Section 3., TERM, shall be amended to extend the termination date from June 30, 2007 to June 30, 2008. 3. Except as herein amended, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Fourth Amendment to Consultant Agreement on the date and year first written above. ATTEST: PATRICIA E. HEALY Clerk of the Council APPROVED AS TO FORM: SEPH W. FUETCH City Attorney APPROVED AS TO CONTENT: ERARDO MOUET, Parks, Recreation and Services Agency CITY OF SANTA ANA 'AMA-;' DAVID N. RE City Manager /-1 - Z/�,9C�-/ . ACORD CERTIFICATE OF LIABILITY INSURANCE TM. DATE ' 1212012006 PRODUCER PNne: (800)395A075 Fmc: (858)5190822 FITNESS AND WELLNESS INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 380 STEVENS AVENUE, SURE 206 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SOLANA BEACH CA 92075 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Zurich North America INSURER B: CHOC V. LE 4 FABRIANO IRVINE CA 92620-2576 INSURER C: INSURER D: INSURER E: - COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITKIN 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 POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAN) CLAIMS. IN SR LTR ^°°L TYPE OF INSURANCE POLICY NUMBER POLCV EFFECiNE MTE PDIIDY PXMATYON DATE LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL Lj1BIL CLAIMS MADE[j]OCCUR 5763733-00 : 12117106 12/1710T EACH OCCURRENCE $ 1,000,000 pgEjq zIM� TO o 1 $ 166,666 MED. EXP (Any ore pm ) $ 2,500 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIESPE X POLICY PRO- LOC PRODUCTS-COMP/OP AGG. $ 3,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea aodEe,H) $ BODILY INJURY (Par Pm ) $ BODILY INJURY (Par e�uelrt) $ PROPERTYDAMAGE Per aoddenl $ GARA3E LIABILITY ANY AUTO AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABUM OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY . RRWRETOr MTNEIMMO rIVE oMERNEMINR UCLUDED] xxEeML MovMmxx mlw wonvTurTnns oTaEa E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE E E.L. DISEASE -POLICY LIMB E OTHER: DESCRIPTION OF OPEPATIONSRbCATIONSIVEHICLESIEXCLUSIONS ADDEDBYENDORSEMENTISPECIAL PROVISIONS SEE SUPPLEMENTAL CERTIFICATE INFORMATION ff /� rFaT1FIr ATF Him nFR 1 11 CANCFLLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 CGmmUn Redevelopment en ity P Agency DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE of the City of Santa Ana INSURER, ITS AGENTS OR REPRESENTATIVES. 20 Civic Center Plaza (M-25) Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE � �_ /f��Vi Attention: Jeffrey E. Frick, ACORD 25 (2001108) Certificate # 51125 R E C E ; _ :. " v 11 0 ACORD CORPORATION 1988 SUPPLEMENT TO CERTIFICATE OF LIABILITY INS #51125 DEC 2006 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS The City of Santa Ana, and the City of Santa Ana, located at 20 Civic Center Plaza, Santa Ana, California 92701; and their respective otfii employees, agents, volunteers and representatives are named as additional insureds ("additional insureds") with regard to liability and of suits arising from the operations and uses performed by or on behalf of the named insured. Additional Insured Endorsement Is Effective: 12101/06 Certificate # 51126 CG 20 10 11 85 DATE: DEC 20 06 POLICY NUMBER: 5763733-00 INSURED NAME: CHOC V. LE 4 FABRIANO IRVINE CA 92620-2576 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Job/Project: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work- for that insured by or for you. Primary Insurance it is agreed that such insurance as is afforded by this policy for the benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and noncontributory, but only as respects any claim, loss or liability arising out of the operations of the named insured(s) or its subcontractors, and only if such claim, loss or liability is determined to be solely the negligence or responsibility of the named insured. Notice of Cancellation or Non -renewal it is agreed that the company will provide the additional insured shown below with 30 days notice of cancellation of this policy in the event of cancellation due to company election only. WAIVER OF SUBROGATION It is agreed that we waive any right of recovery we may have against the person or organization shown in the schedule because of payment we make for injury or damage arising out of "your work" done under a contract with that person or organization. The waiver applies only to the person or organization shown in the schedule. SCHEDULE - -- -- -- - NAME OF PERSON OR -ORGANIZATION - The City of Santa Ana, its Respective Officers, Employees, Agents, Volunteers and Representatives 20 Civic Center Plaza (M-25) Santa Ana CA 92701 DATE (MNI!DG(YYW) ACORDTN. CERTIFICATE OF LIABILITY INSURANCE 10111512005 PRODUCER Plwne: (ICO)B55 W15 Fae. 1858)5t5-0S:: T418 CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION FITNESS AND WELLNESS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE F FIT ESSASTEVENS D AVENUE, SUITE 206 HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 41TRR T4E COV RAGE AFFORDED BY THE POLICIES BELOW. SOLANA BEACH CA 92075 INSURERS AFFORDING COVERAGE NAIC ti INSURED CHOC V. LE 4 FABRIANC IRVINE CA 92620-2576 ANY PERTAIN, THE CONDITION TERM OR L INSURANCE AFFORDED BY THE POUCHES DESCRI �MCIES. AGGREGATELIMITS SHOWN LIAY HAVE SEEN REDUCED BY 2 I'mla TYPE OP INSURANCE POLICYNUYBER ?R :N9e21i --.. ; GENERALLUBIUTV PHPK215311 XX-+' CCOOMMERCIALGENERALUASILITY CLAIMS MAOE� OCCUR A _ X 1 POLICY _ JECT AUTDYOBaE LNABILRY ANY AUTO ALL OWNED AUTOS ' SCHEDULED AUTOS I y HIREOAUTOS ~—I NONOWNEDAUTOS —yI GARAGE LIABILITY ANY AUTO EXLE351 UYBREL�.A LIABIDtt I OCCUR _ CLAIMS MADE NDEDUCTIBLE RETENTION $ .RER$ COMPENSATION AND DESCRIPTION OF OPERATILINWLW%,A"I-n'eL'— SEE SUPPLEMENTAL CERTIFICATE INFORMATION Community Redevelopment Agency of the City of Santa Ana 20 Civic Center Plaza (M•25) Santa Ana CA 927D1 Attention: ACORD 25 (2001108) ra INSURER 8: _ .. INSURER C: T WITH REspt:L= SUBJECT TO ALLTE SEssueD gou:ONS OF UNITS WED. EXP IAny ale Perem) PERSONAL A AM INJURY GEERALAGGREGATE CONSIEDSINGLELIIAT (Ea r=Hiwt) BODILY INJURY [Per person) .I BOOILYMUURY Wer aaiMNl OTHER THAN L&15 ' AUTOONLY: AGG S EACH OCCURRENCE --is AGGREGATE I> I '$ r- EACHACCIDENT IS j£L DIBFASEEAEWI.OYEE 'S _EA. OISEASE.POLICY LIMIT I$ ENDORSEMENT! SPECIAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DAYS BIINSURER WILLENDSAVOR TO MAR-30 WRITTEN NOTICE TO THE OCERTIFIF TH.E GINHOLDER NAMED TO THE LEFT BUTFAILLURE TO DO BO SHALL IWOSE NO OBLIGATION OR LIASILRY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATNES AUTHORIZED REPRESENTATIVE J .I�. Frick. CEO _ DATE SUPPLEMENT TO CERTIFICATE OF LIABILITY INS #67706 JAN 7s oa DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS ittddit demnal to d a but reed as that the respe is the operations of thof Santa Ana, le named insured except that liabilers) employees, ity resultilunteers ng from nd rthe additional nsureds sale Additgence ' This Insurance Insured Endorsement isprima ry and snon-contributory ontr butory to any other insurance held by the insured. Certificate K 67706 CG 2010 1185 DATE: JAN 15 08 POLICY NUMBER: PHPK215316 INSURED NAME: CHOC V. LE d FABRIANO lRVINE CA 92620.2576 HE POLICY. PLEASE READ IT CAREFULLY THIS ENDORSEMENT CHANGES T ADDITIONAL INSURED • OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Person or Organization: JobfPrOject: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) rson or d the WHO edule, N INSUREDith (respect totliability arising tout of 'your work' for o include as an that insured by or foayoution shown in the Sch efit Of the ditionai Primary Insurance it is agreed that asuch nd any other nsuran insuranceas is maintainednta ned by the additional rded by this policy for the nnsured(s) shalll be excess shown shall be primary i loss or liability arising out of the operations of the named and non-contributory, but only as respects any claim, loss liability liability is determined to be solely the negligence or insured(s) or its subcontractors, and only if such claim, responsibility of the named insured. the company ll vide e additional insured shown wNotice of Cancellation or ith 0 days notice of cancellation of this l it is agreeln the tevent of cancellationdue to company election only. below WAIVER OF SUBROGATION have It is agreed mat we waive any right of recovery a may r injury or da age arising out ofnst the person or nyourowork' Shown in the schedule because of Pay lies only to the person or done under a contract with that person or organization. The waiver applies Y organization shown in the schedule. SCHEDULE NAME OF PERSON OR ORGANIZATION City of Santa Ana, it's Respective Officers, Employees, Agents, Volunteers and Representatives. 20 Civic Center Plaza (M-25) Santa Ana, CA 92701