HomeMy WebLinkAboutTASSA CONSULTING GROUP, LLC 1AINSURANCE NOT ON FILE
WORK MAY NOT PROCEED
CLERK OF COUNCIL
DATE: 5- I ~ -~,~'
L7 ~. CL~h~m. ~~~ ~Z~
CGw~S ~~~~~~"
FIRST AMENDMENT TO
CONSULTANT AGREEMENT
A-2008-094
THIS FIRST AMENDMENT TO CONSULTANT AGREEMENT, is entered
into on May 5, 2008, by and between Tassa Consulting Group; LLC, and Snodgrass &
Micheli, LLC (hereinafter jointly and severally "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 Agreement #A-2007-208, dated August 2Q 2007,
(hereinafter "said Agreement") by which Consultant has provided consulting services
in relation to applying for an extension of an Enterprise Zone designation.
B. In accordance with the terms and conditions of said Agreement, the parties wish to
amend the Scope of Services, extend the termination date and increase compensation
to pay for the additional services.
WHEREFORE, in consideeation of the covenants contained in said Agreement, and
subject to all the terms and conditions of said Agreement, except those amended in this
First Amendment to Consultant Agreement, the parties agree as follows:
I . Section 1, SCOPE OF SERVICES, shall be amended to state that Consultant shall
provide services required to obtain final Enterprise Zone designation, obtain approval
of the proposed TEA and obtain state approval of the proposed expansion, as set forth
in Exhibit A-1, attached to this First Amendment to Agreement.
2. Section 2, COMPENSATION, shall be amended to increase compensation by
$30,000, for a total not to exceed amount of $102,000.00 during the term of said
Agreement. During the extended term, from May ], 2008 through October 31, 2008,
City agrees to pay and Consultant agrees to accept as total payment for its services, a
monthly fee of $5,000.00.
3. Section 3, TERM, shall be amended to extend the termination date to December 31,
2008.
4. Except as hereinabove amended, all terms and conditions of said Agreement shall
remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to
Consultant Agreement on the date and year first written above.
CITY OF SANTA ANA
ATTEST:
l
.~,r PATRICIA E. EALY
Clerk of the Council
DAVID N. RE
City Manager
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
By:
Lau a Sheedy
Assistant City Attorney
APPROVED AS TO CONTENT:
' ll'~I
1e~$TEPHE G. HARDING
~U~ _Deputy City Manager for
Development Services
TASSA CONSULTING GROUP, LLC
REX HALVERSON
Owner
SNODGRASS &MICHELI, LLC
-c"
CHRIS MICHELI
Owner
EXHIBIT A-I
Consultant shall continue to assist the City of Santa Ana with its Enterprise Zone needs
as follows:
1. Complete the terms of the Conditional Designation as required by HCD
2. Assist Santa Ana with negotiating and finalizing the MOU with HCD
3. Obtain Final Designation of the EZ by HCD
4. Obtain approval of the proposed TEA by HCD
5. Obtain state approval of the proposed expansion
The services provided pursuant to this Statement of Work will be complete within six (6)
months of commencement of said services. During that time, City shall pay and
Consultant will accept as total payment for its services provided pursuant to this
Statement of Work, a monthly fee of $5,000.00, for a total amount which shall not exceed
$30,000.00.
.
r" 6-444..00 12
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Sel' Il7 Z887 14:!ib::U
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USM INSUR1'\.NCE AGENCY,
812846 P: (1l88}242-1430
PO BOX 33015
SAN ANTONIO TX 78265
-
INC/PHS
F: (877)905-0457
LAA DA TE
DaDe 09-07-2007
THIS CERTIFICATE IS ISSUED AS ~ 'lATTER OF INFORMATIO/II
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOE!; NOT AMEND. EXTEND O~
ALTER THE COVERAGE AFFORDED BY THE POUClES BELOW.
ACORD*
CERTIFICATE OF LIABILITY INSURANCE
INSURERS AFFORl liNG COVERAGE
"'\."RkElartfor-d Casuall~'y :ns Co
.....RER..Hartford Fire Ins Co
MI
TASS A CONSULTING GROUP, LLC
5S5 CAPITOL MALL STB 410
SACRAMENTO CA 95814
COVERAGES
THE POLiCKS OF jN5Uf\ANCE lISTED BELOW HAvt BEEN lSsueo TO nIE tNSUflED NAMED A8DVE FOR THE POLICV PERle 0 INOtCATEO. NDTv.nHST ~
ANY REOUlflENtNT. TEAM OR CONDITION OF ANY CONTRACT Oft OTHER DOCUMENT WITH N:SPECT TO 'NHICH THIS CtiU FreAn NAY BE ISSUED OR
!\olAY PERTAIN. THE. INSURANCE AFFORDED BY THE POUCIES OESCFWBEQ HERE-II IS SU&JECl TO AL.L THfi: TERMS. EXctU:;IO'lS "NO CONDITIONS Of SUCH
POueJE$. AGGReGATE LlMrTS SHOWN YAY HAVE BEEN ReDUCED BY PAlO C~,,~"
~ nwM~ NJUt;y......... "'~ tFFK7NE HLICYQMA1JlMI
IN$Ui'lDl b:
IINS1JflfRE:
IN$Ul!91 c~
~
GE..Al UUIUTY
A t_OA<SINERALl_rTY 65 SBA TI'l8898
CLANS,ljIJAO( [KI DCaJSl
X Business Liab
i.AD-I oc.CU1~&lCe
0'5/04/07 05/04/08 '''''''''''.'''''",m.''''
,..mElCPfMV_I)""HtIII
PStSOf\IJlI...At1lINJIJI'N'
G91ERN. JtG~R(G"'Tf
'PfIOWC'S CQMP'CIP AGG
A~E'WA.m'
ItffMJTO
JIU OWNlD AUTOS
SDtEOl.A.EtJ AUTOS
HIltEO AUTOS
HCtf-QWlIIEDAlJTOS
COMBlH[DSNGlELNIT
rF. woc:ld.-.t)
.
eTHER n- ~
M1TO DN\ Y:
f;A.IIoCC .
"'. .
BODllY".AJ!l'r'
f'''....~
BODl. Y ., JUIlV
W...ar;ci.d,...rl
PftOP'mr' O,....~GE:
1P_lIccid....t}
GAMGl U".'""
NoN JillJTO
NJTa ON 'i - 1:* J.CCtoDtT .
Vta$$ U411JUTY
OCCUA L C.L ANS MADE
E.ACH OCLn.~B\lCE
AGGAEGA TE
OE:OUCTI&.E
RETtNTlON $
wo.tJI!(M~no.AIllD
t;:APtovwrs" .."'MUrY
65 WEC NW0982
0-;/27/07 07/27/08
x :rc t;~r"i' OTH.
~.l EA.1:'>4 .lol:!~DrNi
~.~E~SE E~~NPLOYfE
u., btSEME . !'OLlCY lNIT
.1,000,000
11,000,000
.1 000 DOC
B
au,."
bE$CItIf>TIINICFOPUA'Tot]IIIMS,toc..llJlONSNfiilCl.U6JtUUS1tJ111SAlItl(tIIYnlJg -......."./$HaIlllllfD....,,.
Those usual to the Insured's Operations.
,.,.....
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City of Santa Ana
Ray White-Economic Dev Specialist
Community Development Agency
20 Civic Center Plz # Plaza-
Santa Ana, CA 92701
GANCELLATION
10UlD Alf,y OF lHE ABOVE DESCRIBED PlllK:Il;S St; CANCEllED BEFORE THE j
~ATION OA1E''''"Uf\EOF. THEtsslJt4G 1,."SlJR'Eft WI.L ENOE'-'VORTON~L .
) OAYS WflTlEN HCTIC{ 110 DAYS FOR I\ON,PAYMENT! TO THE CERTrFI i..
OLDER ....-uEO TO THE LEFT. BUT FALURE T[1.DO so SHALL IMPOSE NO f'
IJ..IGATION OR UABlUTY of ANY KltolO UPON THE INSURER, ITS AGENTS OR
PRESENTATIVES.
CERTIFICATE HOLOER
~ ADfAlT.Ir:HMLJIt$tJItED:....l:RUna
Atn'HOIlInD ItEMfliENrA 1JIIE
. ~~--~'5'~
ACO~D 25.S 171971
g ACORD CORPCRATION 1988
AGENT copy
070522 140355
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Sap 12 07 09:54a TASSA CONSUl TING
Sap 12 2007 S:OS FI _ITV INSURANC~ SERVIC
P' ~-444-0012
51G 95145
DECLARATIONS
1"''''ACH 10 YOUR 'OLJC~
- UN I GARD 1 NSLJ'tANCE CO.
p.D-eOX 90701
8fLLEVUE, WI>.. 98009-07<l1
PQl.H:'V ..._.eft "FEe,.,... c"'''~E'VI'
DAn
!'>C121328 04/20107 07 / 01/08
T
CITY U
1
55077 04
NAMED INSlREO AND lIoIAI.lNG ADORE1iS
Effective at 12:01 A.M. stancard time on the datss ~'
ebovs st the address of the named Insured this
AMENJED DECLARATION ' i1.
replaces all prior declaratlcnE;. It any. and witHi"
~,rovisions snd endorsemenH;, if any issued to form a
thereof complates this PERSONAL UMBRELLA LIABI!.! - ..
F'OLlCY.
AGENT
(510) 548-8200
FIDEL I TY INSURANCE SERV I CE I NC
PO BOX 2096
BERKELEY CA 94702
REX HALVERSON
255 CASCADE FALLS DR
FOLSOM CA 95630
OOVERAGE UNITS OFILIABIUTY RETAINEDUMIT .
PERSONAL LIABILITY $1 ,000.000 EACH OCCURRENCE $ 250
EXCESS UNIN5\RED AN:> NOT COVERED
LN)EIlINSURED MOTORIST
sot:eJ.8 lO OF UNDE1~ YI E
T Polic Number Company Limits of Liability
PERSONAL L I A81 L I TV Lt-I125806 lA'l:GARD $ 300.000
20021251 U>lIGARD $ 500.000
AUTO LIABILITY
LIABILITY UA125806 lA'lIGARD $ 500.000 SINGLE,
ISC. AlITO L I ASI LI TY 10136859 lA'l I' GARD $ 500.000 SING-E'
--....;;;:
.
TOTA_ ~REM'UM
ENDORSEMENTS (attached to aoo form ing a pert therE,ofl:
1.03272 03-05. 103270 03-05. 148105 03-05. 154106 03-05. UNO001 10-01,
UN0023 05-05
VEHIQE ADDED
VEHIQ...E CHANGED
RECREATIONAL VEHICLE UNDERLVING ADDED
;#pZIL
II
ADO I T I ONAL PREM I UM TH IS ENDCRSEMENT
DATE -
ACiENC'Y
ct:ILl'fnRSICNED !!IV
05122/07
150
SAC
S08EOlllOlIlt>.lirlUCl327l,..". '.;~'
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SS!, 12 07 09:54a TASSA CONSllI TING
Sep 12 2007 9:09 FL _ITY INSURANC~ SERVIC
Agent CoFY
00550T.'
:,'-..
PelSOnal Auto Policy . California
Declaration ~ge 1 of 3
eompany:
Unlgard rns..-ance Company
!"Olley Number:
UA125606
Named InsUfed:
Rex H81venoo
255 easc.a.de Falls Dr
FoIsomCA95630
~
fldelity InsurallC" SeMce In<
PO 1loo< 2096
l!edceIey CA 94702
(510) 548-ll2oo
a1'l-444-00~2
510. B61'15
C,.
I
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P,O. Bole 90101 ! It .
Bellevue. WA 98OO!l ,
Ren_1 Ded;lJ'&tion lssUlllll .... 06/05107
replaces a~ prior dedamtions.lfan)l. and with
poky proYi$i<>n!. and endorSements, If any.
issued to fom' II part thereof completes th is
Per.iOf1a1 Aut.. PoliCY., .
C...,.,.. it provided only wIIere a premium .
and a limit ot li-ability Is shoWn for 1IIe
coverage.
Polley perl ocI from 07lCY9lfJ7 to 01J09/Q8
at 12:01 "'.M. 5*-ndard time at 1he
adclress of the named InNAld.
ecwerage Part
Urnls of UabilIty
A.liabllity ~
Bodily Injury and Property Damage ~ each KCidtnl
B. MHIica1 Payments S 5.000 limit
C. Unlnwred lIIIotOrirt
Bodily Injury
S 1 00.000 each aceident
D.~ageTOYourAuto
Qthenhlln Collision
a(;lUal cash value
In Inus dedudlble
CoIhlo<l
adUal cash value
minus deductible
Additional Coverages:
Towing and Labor
Increased Tr8I\Sportatlofl Expense
Waiver of ColsiOll [)eductble
S 30 per day 1$9Ol1 maximum
Total pAlllllum byvelllde
Total prelllillm for policy period
vehicle PrCll\lul'll5
1 2
01 BMW 01 IlMW1
$173 $ 2111
$ 16 $ 17
$ 32 $ ;:1)
$60 S ;.2
$200 ded S~OO ded
$128 $ 131
$500 ded $500 ded
$ 4 S 4
$ 12 !. '12
$ 12 $ -12
$437 $459
$ 896
14,0 14.0
j." ~~ ".~
.
If
J':i~ '~1
consratulatlOlisl The excellent driving record ol your household has earned you our speci'" Accident Free Driver Credit.
This along with your e1i&ibllily for the other eredlt(s) listed beIoo> has reduced your total a~to premium, please
note that tile total p-emium shown abcwe aJreldy Includes the premium reductiOn.
CroSS Sold Credit Renewal credt 12~/'
5% PaS$i'Ie Restraint veil 1.2 15% Anti-Theft DisCOuntVeh 1.2
Accident Free Driver CredII Vetl 1 25 .0%. Veil 2 25.0%
".'
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llllulti-Car Di;aunt Veh 1,2
Good Studlmt ()IVT 3
} 'M'
lHANIC YOU FOR QtOOSING UNKiARD FOR. YOUR lNSURAN'CE N~tDS." 'r.
'i~' (1,' 100m' ,
, YLf //2.. 11
,,- cI , II'
XI"'" D4.03
~il:'~}
lVIay L:J UI:l UL:L'l:lp I A~~A CON~I'" ING
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Page 883
-Att~ ~. A-:1fJ'DR-Dq4
A -,2001-2Of
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P1DC 05-28-2008
ACORD..., CERTIFICATE OF LIASIUTY INSURANCE
_UClflt THIS CERTIFICATE IS ISSUED AS A ~ATTEA OF INFORMATION
USM ::NSURANCE AGENCY INC/PHS ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE
fiOLDER. THIS CERTlFlCATE DOES NOT AMEND. EXTEND OR
812846 P: () - F: ()- AlTER THE COVERAGf AFFORDED BY THE POLlOE5 BELOW.
INSURERS AFFOflOING COVERAGE
- INSl..ftfRA:Hartford Casualty Ins Co
IfaUtfR II: P.artford Fire Ins Co
TASSA CONSULTING GROUP, LLC IIIIUl a. c:
1201 K ST. STE 1950 aIIUIa. Q;
SACRA."'1ENTO CA 95814 INSUlfR e
COVERAGES
THE POUCIES OF INS'-""NCE U$TEO IIElOW HAVE BEEN ISSUEO TO THE IHSURED HAMED AIlOVE FDA THE POLICY PERIOD I~OICATeo. NOTwnHSTANOING
NIY Mew_MENl'. TERM OR CONOITIOH OF ANY CONTltACT OR OTHER oacUMENT WITH RESPECT TO WHlCtj THIS CERTIFICATE MAY II€ ISSUED OR
MAY "ERlAlN. THE INSUMNCE AFfOfIOIDev THI POUCiEl DUClllIED tiEAIIN 18 8U8JECT TO ALL TJ4f TEAMS. EJCCl.U8IONS AND CONDITIONS OF SUCH
POUCIES. AGGRaJATE UMfTS SHOWN MAY ffAVE IIEEN REDUCEQ BY"NO ClAIMS.
""" W IIlIIUMllIW I'fIUn ......,
AIlt'IW. IIlUIUrY
A !(;OMMUlCW....flW.UAIIlUTY 65 SBA TZ9694
aAlM.Mi'.O! 00 occv..
X, Genera1 Liab
/fHt NJlO
I\lL OlIVlf3) "UT;n
CCM[OUlEl> AUTOS
IoIl11ED IoUTOS
NC:JN.(JWNfo I'tlITO:ll
~AClUA_""
/fHt"UTO
IJttClU 1'-""
A X OQ;UlI L a.-U'AO~ 65 SEA TZ9694
DEDUCTIBLE
X RmNTIOIt .10 000
II'dIIMMI ~"_MrID
B BWI-......",. 65 WEC NW0982
orMJr
u.n
eIoClolOCC\JMIM:" .2 000 000
09/29/07 07{27/08 flM_AQ!lAnyallu.tl .300.000
WS ~~llV_lNI_ .10 000
PONONM.&AO\(INJURY .2 000 000
~ACGfliG4n; .4 000 000
~'CtNl'JOf'I\QO .4 000 000
COIIIIN[O C1NCU UMIr
1'-_1
.
80;JQ. Y il\l.IURY
IP... ....-.l
IIOOILY IMIlJRY
,... -1I'tI
.
1'IlOPSr''t OAMAGE
.... -.....
.
AUTO DIlLY - fA JlCctOfNT .
OTItfR ,""'"
AUTO ONLY;
[AOI OCCl..,IllEHCO:
09/29/07 07 /27/08 AOOIlEOII.r~
~~C .
AGa .
.1 ooe 000
.1,000,000
OfN.
07/27/07 07/27/08 f,l.. ~ACCIDENr .1 000 000
E.1.. JIIU&[. "" EMPLOYE[ .1 000 000
E.L JDEASf. ~ucr LIMIT .1 000 000
~_._~~'lIR.(.IIMI.GIlIlZI.r_"R ~.~~
Those usual to the Insured's Operations.
CERTIFICATE HOlDER ~-..a:_1n'rM:
City of Santa Ana
Ray White-Economic ~ev Specialist
Community Developma~t Agency
20 CIVIC CEKTER PLZ
SANTA ANA,CA,92701
ACOQO 25-5 (7{97l
\I'PR y
FORM
//-.3
f" ')..;is i .-1.'
CANCElLATION
SHOulD AAY Of THE ....OVE OESCRt8ED POLICIES BE C....NCEllED BEFORE THE
EXPIRATION OATE THEREOF. TKE ISSUNCllNSUIIER WU ENDEAVOJIl TO MAl.
DAYS WRITTEN. NOTlCE rl0 DAYS fOR NON-PAYMENT! TO THE CERTIFICATE
HOLDeR ~AMED TO THE lEFT. BUT FAILURE TO DO SO SHAll IMPOSE NO
OIllG4TION OR UA81UTY OF ANY KINO UPON THE INSUAEft ITS AGENTS OR
AEPfIlEIENT ATlVIS.
"'ACORO CORPORATION 1988
I A'-''-'A CUN'"'L" 'ING
IVlay Z'::J UI:S UL:Zl:Sp vv v
.. ~~-c':l.-c~ 1.5= ~~ HALVERSON 9. 989-7831
INSURED COpy 070522 140355
r . ~-444-OO42
p.3
PAGEl
AGENT
l..,...c" '0 "0&1,, POllOI ~~
P'OlI CY NUMIIE" IEl'FEeTl VI; 1')(Jil1'i.....1ON T A GaIT' Sf CITY U
OAn ~TE
PC121328 04/20/07 071 0 1/08 1 55077 04
DECLARA TIONS
'b
U'III GARD I NSUlANCE CO.
P.OBDX 90701
~EVUe. YV~ 98009-070'
~
(510) 548-8200
F I DEL I TY I NSlRANCE SERV I CE r NC
PO BOX 2096
BERKELEY CA 94702
Effective .t 12.-01 ".M. stendard time on the elates shOWn
above lit tile address of the named insured this
AMENDED OECLARA T I ON
replaces all prior declarations. if any. and with policy
provisions and endorsements, if any issued to form a part
thereof completes this PERSONAL UMBRELLA UABllIT'
POLICY.
NMED INStJRED AN;) MAilING ADDRESS
REX HAl. VERSCN
255 CASCADE FALLS OR
FOLSOM CA 95630
COVERAGE
PERSONAl LIABILITY
excess UNlNSlHo AlII)
UNOERINSl.RD MOTORIST
UMITS CFLlABIUTV
$1,000,000 EACH OCClRU:NCE
NJT COVERED
~ OF ~DEAl..YIHC IN~
POlicy Number ComD8ny
UH125608 UNIGARQ
20021251 l-"IIGARD
RET AI NED lIMT
$ 250
Tvpe of Poliev
PERSONAL LIABILITY
~UTO LIABILITY
L , AS I L /TV
MISC. AUTO LIABtLl TV
UA125606
10136659
~ I GARD
LNI GAR[)
limits of l.iabilitv
$ 300,000 SINGLE LIMIT
$ 500,000 SiNGlE LIMIT
$ 500,000 SINGLE LIMIT
$ 500,000 SINGLE LIMIT
TOTAL PREMIUM
$165.00
=NOORSEMeNTS fattaehe<t to and forming a p<<t thereof):
103272 03-05. 103270 03-05. 1~8105 03-05, 154106 03-05. UNO 0 0 1 10-01,
.Jtf0023 05-05
iEH I CLE ADDEO
IEH I CLE a-tANGEo
~ECREA T I ONAL VEti I CLE l..MlERL Y I N3 ADDEO
ADD I T I ONAL PREM I UM THI S ~seMENT
$.00
COUNTEllSIGNED 8V
O....TI!
5/22/07
150
SAC
AGI;HCY
30$ EDmo~ Ie-I!; "0:1271 R[V '-lit
.
IVlay L.':::J U(j UL:L(jP I A::>::>A CUN::>/ I' liNG
tt).c'j-cOOI::1 lq= k1j H-LVt:::l<l;)lJ'.I '3 '.::It:1=:I- (~jl
r~r~urllU ^UCO ,..01 ICY - lolIf IJOrn'lI
Declara'ion Page 1 of 3
" · 6-444-0042
p.4
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Company:
Unigard Insurance Company
Potier NUMber:
UA125606
NIIIIICd ,"HIed:
Rex Halverson
255 Cascade F8b Or
Foisom CA 95830
eUNIGARD
P.O. Box gQ701
BefkJwe. WA 90009
Ch.... To Vow PvIIcy
dfectift; ~
AgeftI: .
Fidelity Inannce S*V1ce1nc
PO Box 209& .
a.rtceI.y CA 84102
(510) 546-8200
No pwtnNM dIIlf'enc&
for..... ch.....
Mt.llidcd DedM~ ....... Oft 08f11/Oi
........,.. aI prior decMlations, . any. .,d with
poIcJ provlsklns and endo....luo.. latty,
iaued tea fom . '*' ther80f CGmJI,'" ..
~ Auto Poley.
01 BMW replacecf WIh 01 MERZ
~ r....... on 0111MW1
os M ERZ revised
Polic:y period from 07fOalO7 tQ 01""
.12:01 A.M. ~ time "the
addrea. of the ...... iMUnd..
~.. ~.., wt.eree prernUI
and . liMit of'''''''' .. aItown for the
cGWIMIge.
eover.oe Part
u.... of u.biItr
Vehicle Pre........
1 2
08 LfERZ 01 8MW1
A. liability
eoc.ty Injury iIlOd Property D.iunilge 1500.000 MCh accident
. 8~ ~I p&yMe,",1B
. 5,000 Irnit
S 188 $201
S 15 .'17 -. :~p .--
$32 $30
$65 $52
S200 d&d $20() ded
$133 S 131
$500 ded S500 ded
$ 4 S "
$ 12 $ 12
$ 12 S 12
$"1 $459
$ 100
c. Uninsured MaIIDrist
Bodily In~
D. Damage To Your AUlD
oth<< Than Collision
$100,000 each accident
actual cash "....
minus deductibre
Cof&&ion
actual caah v-...
mlnul deductible
Addition.. Cove,...:
T owinv and Labor
Increased Tr_~ Expense S 30 per day JS900 ....imum
WlliWrol~ ~
Total ....... by ve,..
ToW premiuM for poIicj period
THAAK YOU FOR CHOoSING UMGARD F()R YOUR INSURANCE NEEDS.
100TTlCA
~ze"Q I 4J'..,
Jurl L4 Utl U~..)oa
I A""A CUN::iUL liNG
916-444-004::
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'. 82
09
NW
Wi':C
(Policy Provisions: NC 00 00 00 A)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
.
NCCI Company Number:
Company Code: 1
13269 I
USAA #: 001468982
A - 2C\J<6 - o-cr+
THE X
HAR TFORD
INSURER: HARTFOR;) FIRE INSURANCE COMPAi'IY
HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115
M
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,.,
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o
POUCY NUMBER:
Previous Policy Number:
HOUSING CODE: DX
1. Named Insured and Mailing Address: TASSA CONSULTING
(No.. Street, Town, Slate, Zip Code)
Suffix
LARS RENEWAL
c=J 02 I
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165 WEC NW0982
65 WEe NW0982
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GROUP, LLC
FEIN Number: 203553547
State Identification Number(s):
UIN:
1201 K ST. STE 1950
SACRAMENTO, CA 95814
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The Named Insured is: LIMITED LIABILITY COMPANY
Business of Named Insured: LAWYERS & LAW FIRMS
Other workplaces not shown above: AS STATED AND ELSEWHERE IN CALIFORNIA
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2. Policy Period: From 07/27/08 To 07/27/09
12:01 a.m., Standard 1ime at the insured's mailing address.
Producer's Name: USAA INSURANCE AGENCY INC/PHS
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PO BOX 33015
SAN ANTONIO, TX 78265
Producer's Code: B12 84 5
Issuing Office: THE HARTFORD
3600 WISEMAN BLVD.
SAN ANTONIO TX 78251
{8BBl 242-1430
Total Estima1ed Annual Premium: $1.072
Deposit Premium: $1,072
Policy Minimum Premium: $1, 000 CA (INCLUDES INCREASED LIMIT
Audit Period: ANNUAL Installment Tenm:
The policy is not binding unless countersigned by our authorized represen1ative.
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Countersigned by
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06/14/08
Dale
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Authorized Representative
Form WC 00 00 01 A (1) Printed in U.S.A.
Process Date: 06/14/08
Page 1 (Con1inued on next page)
Policy E><piration Date: 07/27/09
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INFORMATION PAGE (Continued)
Policy Number: 65 W,C NW0982
3. A. Workers Compensation Insurance: Part one of Ihe policy applies to the Warke", Compensation Law of the
states listed here: CA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily injury by Accident
Bodily injury by Disease
Bodily injury by Disease
$1,000,000
$1,000,000
$1,000,000
each accident
polic\, limit
each employee
C. other States Insurance: Part Three of the policy applies to the states. if any. lislr,d here:
ALL STATES EXCEPT NO, OH, WA, WY, AND
STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
WC 04 01 04 WC 04 03 03 we 04 04 16 WC 99 03 03B .]C' 04 Oil 03
SEE ENDT
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
Premium Basis
Total Estimated
Annual
Remuneration
Classifications
Code Number and
Description
8BlO
CLERICAL OFFICE
Rates Per
$100 of
Remuneration
Estimated
Annual
Premium
91,600
.72
660
EMPLOYEES-N 0 C
CA TERRITORIAL DIFFERENTIAL PREMIUM 9694 10.950)
TOTAL ESTIMATED Am.'UAL STANDARD PREMIUM
TO EQUAL MINIMUM PREMIUK (0990)
':'OTAL ESTIMATE!) ANNUAL STANDARD PREMIUM
BROAD FORM - EXTENDED (9702) 1.50 PERCENT
CA SURCHARGE 2.000 PERCENT
USER FUNDING ASSESSMENT 1.0703 PERCENT
FRAUD ASSESSMENT 0.2394 PERCENT
CA UNINSD EMPL BENEFIT TRUST FUND 0.1730 PERCENT
CA SUBSEQ INJ BENEFITS TRUST FUND 0.0311 PERCENT
FOREIGN TERRORISM (9740) 91,600
TOTAL ESTIM!\TED ANNUAL PREMIUM
.030
.-33
627
373
1,000
9
2:'
11
2
2
o
27
1,072
Total Estimated Annual Premium:
Deposit Premium:
Policy Minimum Premium: $1,000
$1,072
$1,072
CA (INCLUDES INCREASED LIMIT HIN. PREM. )
InterstateJIntrastate Identirication Number:
Labor Contractors Policy Number:
NAICS:
SIC: 8111
UIN:
NO. OF EMP:
000002
Form we 00 00 01 A (1) Printed in USA
Process Date: 06/14/08
Page 2
Policy Expiration Date; 07/27/09