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Home My WebLink AboutILLUMINATION FOUNDATION (42) INSURNNc!-ON ,;AL' WORK M,4 1)1,'01TL.0 UNTIL i,N iRes A-2021-175-01A CITY TLE. DATE. APR ? 9 2025 �'�➢��',� MAYOR CITY MANAGER �rlW��h r Valerie Amezcua Alvaro Nunez MAYOR PRO TEM R�_;,'� CITY ATTORNEY Benjamin Vazquez - -__ - Sonia R.Carvalho COUNCILMEMBERS CITY CLERK Phil Bacerra g>' - Jennifer L.Hall Johnathan Ryan Hernandez Jessie Lopez David Penaloza Thai Viet Phan CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY 20 Civic Center Plaza—M25 Santa Ana,California 92702 www.santa-ana.ora April 15, 2025 Illumination Health+ Home Attn: Pooja Bhalla,CEO 2871 Pullman St. Santa Ana,CA 92705 Re: Extension of Agreement A-2021-175 to Operate a Year-Round Homeless Navigation Center Pursuant to Section 2("Term")of the above-referenced Agreement,entered into by The Illumination Foundation("Contractor")and the City of Santa Ana,dated September 7, 2021, the time period of the Agreement is hereby extended for an additional two(2) year period until May 1,2027. By operation of this letter, and pursuant to Section 14 of the Agreement, the City recognizes the change of company name to Illumination Health+Home. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. /Sincerely, Q y Michael L. Garcia Executive Director, Community Development Agency CITY SAI TA ATTEST = f Alvaro Nunez ennifer L. iall City Manager C' APPROVED AS TO FORM ILLUMINATION HEALTH+HOME Andrea Garcia-Miller Name: Woja Bllalla Assistant City Attorney Title: Chief Executive Officer SANTA ANA CITY COUNCIL Valerie Amezcwa Benjamin Vazquez Thai Viet Phan Jessie Lopez Phil Bacerra Johnathan Ryan Hernandez David Penabza Mayo r Mayor Pro Tem-Ward 2 Ward t Ward 3 Ward 4 Ward 5 Ward 6 yamezMa bvazouez(@santa-ana orq tpharKa�santa-ana orU tessielopP dsanta-ana org pbacemaAsanta-anao irvanhemandezr_c�santa-ana.ofp dcenaloza0santa-ana ora AC�® DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 411/1015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONIAUl NAME: Liz OrOZCo Cure Brokers Insurance Services FHUNE RRR 426-7344FA A/C,No Ext: ( ) (AIC,No): 4101 McGowen Street ADDRESS: liz(e'corebrokers.com Suite 110-446 INSURER(S)AFFORDING COVERAGE NAIC# Long Beach 90808 INSURER A: Cypress Insurance Company 10855 INSURED INSURER B: QBE Specialty Insurance Comany 11515 The Illumination Foundation INSURER C: Berkshire Hathaway Homestate Companies 20044 2871 Pullman Street INSURER D: Underwriters at Llyods N/R INSURER E: Santa Ana CA 92867 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYV (MMIDDIYYYY) LIMITS V COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE § 2,000,000 CLAIMS-MADE ERIOCCUR PREMISES(Ea occurrence) $ 50,000 Including Professional Liability MED EXP(Any one person) $ 5,000 B Y Y [40002207 12/01/2024 12/01/2025 PERSONAL&ADV I NJ URY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 MPOLICY ❑PE� LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: Prof Liab:Each/Agg $ ?,000,000/4,000,000 AUTOMOBILE LIABILITY {Ea accident S 1,000.000 ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED Y Y 01 APM053501-01 12/01/2024 12/01/2025 BODILY INJURY(Per accident AUTOS ONLY AUTOS ) S HIRED NON-OWNED S AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE S DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY y/N K STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT S 1,000,000 A OFFICERIMEMBEREXCLUDED? NIA Y ILWC613770 01/01/2025 01/01/2U26 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000.000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 One Victim 2,000.000 D Sexual Molestation Liability B062IPILL0001324 12/01/2024 12/01/2025 All Victims 2,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Santa Ana,its City Council,its officers,officials,employees,agents and volunteers are included as Additional Insured as required by written contract per attached endorsement form.Primary and Non-Contributory wording applies.Waiver of Subrogation per attached endorsement form.30 Days notice of cancellation; 10 Days for Non-payment applies per policy provisions. Digitally signed APPROVED Tu Tran hyr.rrzn Nguyen Nguyen Date-:o-s.oa.os B Tu Tran Nguyen at 4:56 m,Apr 08,2025 laszlg-mno� YP P CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Community Development Agency AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza,M-25 P.O.Box 1988 Gkriq Trade" Santa.Ana CA 92702 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Carnegie Navigation Center Operating Budget-200 Individuals PERSONNEL Title FTE Montle Sala X of Month nnual s A Bene tils Annual sale Year 4 12 mo Cost Year 5 12 mo Cost MatchlLever e On-Site Program Stall Sile Maraer 100% 6.ktix 12,00 25% $109000 100000 $103,000 Assodale Site Mane er 100% 6 720.DC 12.00 25% 85 800 $85,600 $86 374 Lead Client Cafe Assoclate 100% 3.813.33 12.00 25% $57,200 $57 200 55,815 Intake s eoiallst Site Assistant 100% 4 087.20 12.00 25% $61 306 1.306 $53,147 Site Assislant 100% 3,805,33 12,00 25% 54 080 $54,D80 $55 702 Site Assislant 100% 3.466.67 12.00 25% $62 000 $52 000 53,560 611e Asslalent 100% 3466.67 12.00 25% $52009 52,D00 $53,560 Site Assistant f00% 3466.67 12.00 25% 52.000 $52,D00 $53560 Site Assislant 100% 3A66.67 12.00 25% $62.0001 $52000 $53,560 Site Assistant 100% 3466.67 12.D0 25% $52000 520n0 $53,560 Site Assistant 100% 3466.67 12.00 25% $52.00 52,0001 $53,560 Me Assistant 100% 3.466.67 12.00 25% $52.000 $52000 $53,660 Site Assistant 100% 3468.67 12,OC 25% $52000 $52,0o0 $53,60D Site Assistant 100% 3 468,67 12.00 25% $52.000 $62.000 $53 580 Site Ass€stanl 100% 3,466,67 12.DC 25% $52.000 $52 000 $53,560 Site Assistant 100%1 346367 12.00 26% $52000 52,000 0,3.56D Site Assistant 14)0%1 346567 12.00 25% $52.000 S52,000 $53660 Site Assistant 100%1 3,466,67 12.00 25% $52 000 $52 000 $53,56D Site Assistant IOG%l 3,458,67 12,00 25% $62000 $52,00C $53,55D Bite Assistant 0% 5466,67 12.00 25% $52,00 Sc Transportation Coordinator 100% 3,749,20 12.00 25% $68 238 56 238 $57,925 $1,142,626 $1,170,906 Housing&Casa Management Director of Housing&Case Management 20% 7 50D.00 12.00 25% $112 500 $22,500 $23 175 $155 400 Mena sr of Hceln &Case Management 50% 1,720.00 12.00 25% $85.800 S42 800 44 187 88.374 Intake S eciallsi 0% 3,927.73 12.00 25% $56 916 $0 $0 Pro ram Coordinator 60% 5,373.33 12,00 26% $80 800 $40,300 $41 509 $83 018 Lead Case Manager 100% 4,853,33 12.00 25% $72.800 $72 800 174,984 Case manager 100% 4,330.33 12.00 25% $65 00C 366,00D $66,960 Case Manager 100% 4,333.33 12,00 26% 65,000 $65,COD $68 950 Case Manager 100% 4,333,33 12A0 25% $65.000 $65 000 $fi6,950 Case Mena er 100% 4,333.33 1240 26% $65 000 $65.000 $66 950 Case MAP.., 100% 4,333.33 f2 00 25% $65.000 $65 000 $38 257 Lead Hsusir Navi ow 100% 6.113.33 12,00 25% $7131AU $158.002 HousingNavl alor 100% 4,760.37 12,00 25% $71 500 $147 290 Housin Navigator 100% 4,766.87 12,00 25% $71,500 $147,290 HousingNavi elor 100% 4.853.33 1200, 25% $72,600 $149.968 HousingNavl alor 100% 4,553.33 12A0 25% $72 800 $149 968 HousingNavi alor 100% 4,953.33 12.00 25% $72800 $149,96$ $603,509 $489,912 $1,259,278 Culling Executiv.Chef 0% 6260.D0 12.00 25% $93 750 0 $0 Assistant Chef 50% 5 720.00 12,00 25% 85,800 $42.900 $44,187 $08 374 CockI 100%1 4333.33 12.00 25% $65,000 $65000 $66950 Cook I 100% 4,160.00 12.00 26% $62,400 $82.400 $64.272 Cook 1 50% 4.100.00 12.00 25 $62,400 $31.200 $32.136 $201,600 $20T,545 $88,374 Referral Coodlnation Associate Manager of Refenal Coordination 0% 5 833.33 12.00 25% $87.600 90.125 Referral Coordinator 0% 4.333.33 12.1f0 25% $65 000 $66 950 Referral Coordinator 0% 4,233.23 12.00 25% $65.0nal $66 950 Relerral Coordinator 0% 4160.00 12.0 25% $62,400 $641272 Relerral Coordinator 0% 4.160.00 12.00 25% $62,4001 $64272 $0 $0 $052,569 Substance Counciiing M+ iale ManNel of suwlame Musa Counselors 50% 5,720,00 12.00 25% $85,800 $42,9D0 $44.187 $86374 Substance Use Counselor 100% 4,793,13 12.05 25% $71,942 $71.942 $74.1 D0 - Substance Use Technician 100% A,160,00 12.00 25% $62400 $62,400 $64,272 $177,242 $182,659 $88,374 IFMO Medical Norse Prsat€llaner 100% ID,OOD,OD 12.0C 25% $150000 $309000 Enhanced care Manager 100% 3,956.67 12.00 25% $59,800 $123.18 Medlrnh assistant 100% 3,813.33 12.00 25% $57.200 $117.832 Enhanced care manager i 100%i 2,00 25% $58,600 $120 51 1 $67D,530 TOTAL m, 142.701 168,739.00 1 1 12.105,500.0012,024,a68.D8 2,056,921.18 2,459,125.00 On-site Daily Number of Program Staff:pally site aids 12 over two shifts OmSfte Night Staff:4 PROGRAM D-orl don Monthly Cost Year 4112 mo Cost Year 5 12 mo Cost In-kind 1 Leverage Cllent Trans ortallon Vehicles,fuel maintenance,Insurance $7 528 $90,336 $90.336 Bus PasaoslRlde sharp BusiJbeNL 0 $800 $9.600 $9600 MeafslSnacksMevera es 3Meals p.r day,,nucim and drinks $44025 $536500 $551,565 MeaWSnackslBevera es Oonated Poed for Clients 40 $0 $0 $438460 ShotresuppF.. Paper Goads TP $5.500 $66 000 $66 DDC Pel care Food supplies,limited pat care $300 43.600 $3.600 Cther Direct Client Needs Laundl,hygiene,diapers,cloild"a $2.150 $26,600 $25 640 Cllent recialion f Incentive Clionlsu ort-Incentive&hollda $760 $9000 $9,000 Medical On-site for Cllent, IFMG Medical Su art or.Lew 0 $0 $0 $121 800 PROGRAM TOTAL $61,fi51 $730,638 $756,901 $560,280 FACILITY COSTS' Description MonUtly Cost Annual Co.( SKudly Services 2 FTEs for 2417 coverage $36 000 $432.000 $432,000 danllorfal service&suppil.. $3.800 $45 600 $45 800 Appliance Re airs f Fumilure Replacement Laund ,Kitchen,Oonns $900 $10,900 M.800 Malulenance Ro airs Ptumbin,deptricIty,NVAC $1,100 $13,200 $13 200 pest Control On-Gain Service $260 $3 OCO $3,000 TeleconnA^&FI T-Mobile,Dial ad $3 000 $36,000 $36.000- Security Equipment Monitoring Camera software and NVR $500 46,00 $8,D00 Insurance Llablll $3250 139,000 $391000 Dls Deal Haza Medico Linens $2.301 $27.600 M27 640 FACILITYTOTAL $51,100 $613 ,20 TM 200 $0 OTHER EXPENSES 0escd tien Monthly Cost Annual Cosl OINce SUPPIl.. Computers,printers,toner.paper $688 $4.266 $9 342 Other Staff OaveF and miso ex. $1.212 $14 540. 516,350 OTHER EXPENSE TOTAL $1,900 $22,000 $26,692 $o Sub Total Direct Expense $283,302 $3,400,704 $3,451,714 $3,019,405 ADMIN OVERHEAD 10% Admin Ovediead de minimus 10%Indirect Costs $28,339 $340,070 $34S,171 $301,941 TOTAL OPERATING COSTS:MONTHLY AND ANNUAL YEAR 4&S.12 MONTHS) $311,731 $3,740,774 $3.796,880 $3,321,346 712/8/2025 E(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jeff Davis Marsh &McLennan Agency LLC PHONE FAX Marsh &McLennan Ins.Agency LLC vC No Ext: 949-544-8481 vc,No: E-M1 Polaris Way#300 ADDRESS: jeff.davis@marshmma.com Aliso Viejo CA 92656 INSURER(S)AFFORDING COVERAGE NAIC# License#:OH18131 INSURERA: QBE Specialty Insurance Company 11515 INSURED ILLUMFOUND INSURERB: Redwood Fire and Casualty Insurance Co 11673 Illumination Health + Home 2871 Pullman St INsuRERc: Berkshire Hathaway Specialty Ins Co 22276 Santa Ana, CA 92705-5713 INSURERD: Underwriters at Lloyd's London 55555 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:542651510 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY 140002207 12/1/2025 12/1/2026 EACH OCCURRENCE $2,000,000 CLAIMS-MADE OCCUR PREMISES DAMAGE TO PREMISES Ea occurrence) ccurrence $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $3,000,000 X El JECT OTHER: $ B AUTOMOBILE LIABILITY 01APM06426901 12/1/2025 12/1/2026 COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION ILWC613770 1/1/2025 1/1/2026 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A PROFESSIONAL LIABILITY 140002207 12/1/2025 12/1/2026 EACH CLAIM/AGGREGAT $2M/$2M D SEXUAL ABUSE&MOLESTATION B0621PILL0001325 12/1/2025 12/1/2026 EACH CLAIM/AGGREGAT $1M/$1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Waiver of Subrogation applies to General Liability,Auto Liability,and Workers Compensation,where required by written contract,per the attached endorsements. Digitally signed by Tran Iran Tu Tran Nguyen Date:2025.12.08 Nguyen 14:56:46-08'00' APPROVED JBy Tu Tran Nguyen at 2:56 pm,Dec 08,2025 �] CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD rXh W QBE_ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY AND WAIVER OF SUBROGATION OPTIONS FOR ADDITIONAL INSUREDS ENDORSEMENT Name of Insured: Illumination Health+Home Policy Number: 140002207 Endorsement Number: 004 Effective Date of Endorsement: 12/01/2025 Name of Insurer: QBE Specialty Insurance Company This endorsement modifies insurance provided under the following: GENERAL TERMS AND CONDITIONS SCHEDULE All Additional Insureds It is agreed that, solely with respect to the Additional Insureds identified in the Schedule and solely with respect to the General Liability Coverage Parts, the Policy is amended as follows if an X is shown in the box: l If the Named Insured has agreed in its written contract with the Additional Insured to provide the Additional Insured coverage on a primary and non-contributory basis, this Policy shall be primary and the Insurer will not seek contribution from the Additional Insured's policy. El The Insurer waives any right of recovery it may have against any person or organization, where required by the Named Insured's written contract with the Additional Insured, because of payments made by the Insurer for Loss arising out of the Named Insured's operations. All other terms and conditions of this Policy remain unchanged. MLPL-HCMM-2020(06-24) ©QBE,2o24 Page 1 of 1 POLICY NUMBER: 01 APM 064269 - 01 M-5144a(06/2007) WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: Countersigned By: 12/01/2025 12:01 AM Named Insured: ILLUMINATION HEALTH + HOME (Authorized Representative) SCHEDULE Name Of Person(s)Or Organization(s): City of Santa Ana, its City Council,elected and appointed officials, and employees 20 Civic Center Plaza Santa Ana, CA 92701 Additional Premium $ 100 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organiza- tion(s)shown in the Schedule. We will retain the additional premium shown above, regardless of any early termi- nation of this endorsement or the policy. Includes copyrighted material of Insurance Services Office,Inc.with its permission. M-5144a(0612007) 12/04/2025 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C (Ed. 9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the applicable manual premium otherwise due on such remuneration subject to a policy maximum charge for all such waivers of 5%of total manual premium. The minimum premium for this endorsement is$350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Specific Waiver Person/Organization: City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers Job Description: Contract with City to provides services to the homeless Waiver Premium: 350.00 Payroll Subject Class State to Waiver 8804 CA 1.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 01/01/2025 Policy No.: ILWC613770 Endorsement No.: Insured: Premium $ Insurance Company: Cypress Insurance Company WC 99 04 02C Countersigned by (Ed. 9-14) EBUF!)NN0EE0ZZZZ* DFSUJGJDBUF!PG!MJBCJMJUZ!JOTVSBODF UIJT!DFSUJGJDBUF!JT!JTTVFE!BT!B!NBUUFS!PG!JOGPSNBUJPO!POMZ!BOE!DPOGFST!OP!SJHIUT!VQPO!UIF!DFSUJGJDBUF!IPMEFS/!UIJT DFSUJGJDBUF!EPFT!OPU!BGGJSNBUJWFMZ!PS!OFHBUJWFMZ!BNFOE-!FYUFOE!PS!BMUFS!UIF!DPWFSBHF!BGGPSEFE!CZ!UIF!QPMJDJFT CFMPX/!!UIJT!DFSUJGJDBUF!PG!JOTVSBODF!EPFT!OPU!DPOTUJUVUF!B!DPOUSBDU!CFUXFFO!UIF!JTTVJOH!JOTVSFS)T*-!BVUIPSJ\[FE SFQSFTFOUBUJWF!PS!QSPEVDFS-!BOE!UIF!DFSUJGJDBUF!IPMEFS/ JNQPSUBOU;!!Jg!uif!dfsujgjdbuf!ipmefs!jt!bo!BEEJUJPOBM!JOTVSFE-!uif!qpmjdz)jft*!nvtu!ibwf!BEEJUJPOBM!JOTVSFE!qspwjtjpot!ps!cf!foepstfe/ Jg!TVCSPHBUJPO!JT!XBJWFE-!tvckfdu!up!uif!ufsnt!boe!dpoejujpot!pg!uif!qpmjdz-!dfsubjo!qpmjdjft!nbz!sfrvjsf!bo!foepstfnfou/!!B!tubufnfou!po uijt!dfsujgjdbuf!epft!opu!dpogfs!sjhiut!up!uif!dfsujgjdbuf!ipmefs!jo!mjfv!pg!tvdi!foepstfnfou)t*/ DPOUBDU QSPEVDFS OBNF; GBY QIPOF )B0D-!Op*; )B0D-!Op-!Fyu*; F.NBJM BEESFTT; JOTVSFS)T*!BGGPSEJOH!DPWFSBHFOBJD!$ JOTVSFS!B!; JOTVSFE JOTVSFS!C!; JOTVSFS!D!; JOTVSFS!E!; JOTVSFS!F!; JOTVSFS!G!; DPWFSBHFTDFSUJGJDBUF!OVNCFS;SFWJTJPO!OVNCFS; UIJT!JT!UP!DFSUJGZ!UIBU!UIF!QPMJDJFT!PG!JOTVSBODF!MJTUFE!CFMPX!IBWF!CFFO!JTTVFE!UP!UIF!JOTVSFE!OBNFE!BCPWF!GPS!UIF!QPMJDZ!QFSJPE JOEJDBUFE/!!OPUXJUITUBOEJOH!BOZ!SFRVJSFNFOU-!UFSN!PS!DPOEJUJPO!PG!BOZ!DPOUSBDU!PS!PUIFS!EPDVNFOU!XJUI!SFTQFDU!UP!XIJDI!UIJT DFSUJGJDBUF!NBZ!CF!JTTVFE!PS!NBZ!QFSUBJO-!UIF!JOTVSBODF!BGGPSEFE!CZ!UIF!QPMJDJFT!EFTDSJCFE!IFSFJO!JT!TVCKFDU!UP!BMM!UIF!UFSNT- FYDMVTJPOT!BOE!DPOEJUJPOT!PG!TVDI!QPMJDJFT/!MJNJUT!TIPXO!NBZ!IBWF!CFFO!SFEVDFE!CZ!QBJE!DMBJNT/ BEEMTVCS QPMJDZ!FGGQPMJDZ!FYQ JOTS UZQF!PG!JOTVSBODFMJNJUT QPMJDZ!OVNCFS MUS)NN0EE0ZZZZ*)NN0EE0ZZZZ* JOTEXWE DPNNFSDJBM!HFOFSBM!MJBCJMJUZ FBDI!PDDVSSFODF% EBNBHF!UP!SFOUFE DMBJNT.NBEFPDDVS% QSFNJTFT!)Fb!pddvssfodf* NFE!FYQ!)Boz!pof!qfstpo*% QFSTPOBM!'!BEW!JOKVSZ% HFO(M!BHHSFHBUF!MJNJU!BQQMJFT!QFS;HFOFSBM!BHHSFHBUF% QSP. 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Y uif ObnfeJotvsfe(t xsjuufo!dpousbdu!xjui!uif!Beejujpobm!Jotvsfe-!cfdbvtf!pg!qbznfout!nbef!cz!uif!Jotvsfs gps Mptt bsjtjoh!pvu!pg!uif!Obnfe!Jotvsfe(t pqfsbujpot/ Bmm!puifs!ufsnt!boe!dpoejujpot!pg!uijt!Qpmjdz!sfnbjo!vodibohfe/ MLPL-HCMM-2020 (06-24) © ,2024 Page 1 of 1 CFUB!Sjtl!Nbobhfnfou!Bvuipsjuz!!)#CFUB SNB#* B!Qvcmjd!Foujuz BNFOENFOU CMBOLFU!XBJWFS!PG!PVS!SJHIU!UP!SFDPWFS!GSPN!PUIFST Dfsujgjdbuf!Ovncfs;Bnfoenfou!Op/; XD.36.2587X217.12 Jttvfe!up;!Jmmvnjobujpo!Ifbmui!,!Ipnf Fggfdujwf!Ebuf;!Fyqjsbujpo!Ebuf;!Beejujpobm!Dpousjcvujpo; 1201203137!bu!23;12!b/n/1801203137bu!23;12!b/n/Qfs!Dpousbdu Uijt!bnfoenfou!dibohft!uif!dpousbdu!up!xijdi!ju!jt!buubdife!fggfdujwf!po!jodfqujpo!ebuf!pg!uif!Dpwfsbhf Dpousbdu/ CFUB SNB!ibt!uif!sjhiu!up!sfdpwfs!qbznfout!ju!nblft!gspn!bozpof!mjbcmf!gps!bo!jokvsz!dpwfsfe!cz!uijt! Dpwfsbhf!Dpousbdu/!CFUB SNB!xjmm!opu!fogpsdf!jut!sjhiu!bhbjotu!uif!qfstpo!ps!pshboj{bujpo!obnfe!jo!uif! Tdifevmf/!Uijt!bnfoenfou!bqqmjft!pomz!up!uif!fyufou!xpsl!qfsgpsnfe!voefs!b!xsjuufo!dpousbdu!sfrvjsft!uif! Nfncfs up!pcubjo!uijt!bhsffnfou!gspn!CFUB SNB/ Uijt!foepstfnfou!epft!opu!bqqmz!up!cfofgjut!ps!ebnbhft!qbje!ps!dmbjnfe!cfdbvtf!pg!jokvsz!pddvssjoh!cfgpsf!uif! Nfncfs foufsfe!joup!tvdi!b!dpousbdu/ Uijt!bhsffnfou!tibmm!opu!pqfsbuf!ejsfdumz!ps!joejsfdumz!up!cfofgju!boz!pof!opu!obnfe!jo!uif!Tdifevmf/ Tdifevmf Boz!qfstpo!ps!pshboj{bujpo!xjui!xipn!uif!Nfncfs foufsfe!joup!b!dpousbdu-!b!dpoejujpo!pg!xijdi!sfrvjsft!uif! Nfncfs up!pcubjo!uijt!xbjwfs!gspn!CFUB SNB/ BMM!PUIFS!UFSNT-!DPOEJUJPOT!BOE!FYDMVTJPOT!SFNBJO!VODIBOHFE/ XD`FM!X217!)1802:*Qbhf8 Ebuf!Jttvfe;!Kbovbsz!12-!3137)Jojujbm* 76/25/2026 (MM/DD/YYYY) A`oRo° CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jeff Davis Marsh &McLennan Agency LLC PHONE FAX Marsh &McLennan Ins.Agency LLC vC No Ext: 949-544-8481 vc,No: E-M1 Polaris Way#300 ADDRESS: jeff.davis@marshmma.com Aliso Viejo CA 92656 INSURER(S)AFFORDING COVERAGE NAIC# License#:OH18131 INSURERA: QBE Specialty Insurance Company 11515 INSURED ILLUMFOUND INSURERB: Redwood Fire and Casualty Insurance Co 11673 Illumination Health + Home 2871 Pullman St INsuRERc: Underwriters at Lloyd's London 55555 Santa Ana, CA 92705-5713 INSURERD: BETA Healthcare Group Risk Management A 99900 INSURERE: Kinsale Insurance Company 38920 INSURER F: COVERAGES CERTIFICATE NUMBER:939912664 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY 140002207 12/1/2025 12/1/2026 EACH OCCURRENCE $2,000,000 CLAIMS-MADE OCCUR PREMISES DAMAGE TO PREMISES Ea occurrence) ccurrence $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $3,000,000 X El JECT OTHER: $ B AUTOMOBILE LIABILITY 01APM06426901 12/1/2025 12/1/2026 COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED FIR ER DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident E X UMBRELLALIAB OCCUR 01003552521 12/1/2025 12/1/2026 EACH OCCURRENCE $1,000,000 EXCESS LAB X CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ D WORKERS COMPENSATION WC251476 1/1/2026 7/1/2026 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A PROFESSIONAL LIABILITY 140002207 12/1/2025 12/1/2026 EACH CLAIM/AGGREGAT $2M/$2M C SEXUAL ABUSE&MOLESTATION B0621PILL0001325 12/1/2025 12/1/2026 EACH CLAIM/AGGREGAT $1M/$1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE: Professional Liability with QBE is written on a Claims-Made form with a retroactive date of 12/01/24. Professional Liability includes Sexual Abuse& Molestation coverage with$1 M each claim and$1 M aggregate limits. Underwriters at Lloyd's London(Miller) Provides$1 M of Excess Sexual Abuse&Molestation coverage under Policy#130621 PILL0001325. City of Santa Ana, its City Council,officers,officials,employees,agents,and volunteers are included as Additional Insured where required by an executed written contract as respects General Liability per attached endorsement.Waiver of Subrogation applies to where required by an executed written contract as respects General Liability and Workers'Compensation per attached endorsements. APPROVED CERTIFICATE HOLDER CANCELLATION By Tu Tran Nguyen at 2:08 pm,Jun 25,2026 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD INSURED: Illumination Health+ Home POLICY#: WC251476 POLICY PERIOD: 01/01/2026 TO 07/01/2026 BETA Risk Management Authority ("BETARMA") A Public Entity AMENDMENT BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS This amendment changes the contract to which it is attached effective on inception date of the Coverage Contract. BETARIvmA has the right to recover payments it makes from anyone liable for an injury covered by this Coverage Contract. BETARMA will not enforce its right against the person or organization named in the Schedule. This amendment applies only to the extent work performed under a written contract requires the Member to obtain this agreement from BETARIvmA. This endorsement does not apply to benefits or damages paid or claimed because of injury occurring before the Member entered into such a contract. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule Any person or organization with whom the Member entered into a contract, a condition of which requires the Member to obtain this waiver from BETARIvmA. ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. WC EL W106(07/19) Page 8 Date Issued:July 01,2022(Initial) rXh W QBE_ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY AND WAIVER OF SUBROGATION OPTIONS FOR ADDITIONAL INSUREDS ENDORSEMENT Name of Insured: Illumination Health+Home Policy Number: 140002207 Endorsement Number: 004 Effective Date of Endorsement: 12/01/2025 Name of Insurer: QBE Specialty Insurance Company This endorsement modifies insurance provided under the following: GENERAL TERMS AND CONDITIONS SCHEDULE All Additional Insureds It is agreed that, solely with respect to the Additional Insureds identified in the Schedule and solely with respect to the General Liability Coverage Parts, the Policy is amended as follows if an X is shown in the box: l If the Named Insured has agreed in its written contract with the Additional Insured to provide the Additional Insured coverage on a primary and non-contributory basis, this Policy shall be primary and the Insurer will not seek contribution from the Additional Insured's policy. El The Insurer waives any right of recovery it may have against any person or organization, where required by the Named Insured's written contract with the Additional Insured, because of payments made by the Insurer for Loss arising out of the Named Insured's operations. All other terms and conditions of this Policy remain unchanged. MLPL-HCMM-2020(06-24) ©QBE,2o24 Page 1 of 1