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HomeMy WebLinkAboutWITTMAN ENTERPRISES, LLC HIPAA BUSINESS ASSOCIATE AGREEMENT -2009V . ' g INSURANCE ON Fit' A- 2009 -059 WORK MAY PROCE, ' FXPIQFI UNTIE. '�,'SURANCF CLERK OF CO`USNCU_ CONSULTANT AGREEMENT THIS AGREEMENT, made and entered into this 1St day of June, 2009 by and between Wittman Enterprises, LLC, a California Limited Liability Company (hereinafter "Consultant "), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California (hereinafter "City "). .S RECITALS rl A. The City desires to retain a consultant having special skill in providing ambulance and N , paramedic billing and collection services for the City's Emergency Medical Services M d Program. ej �- B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant shall provide EMS billing and collection services as set forth in Exhibit A, attached to this Agreement and incorporated by reference. 2. COMPENSATION City agrees to pay, and Consultant agrees to accept as total payment for its services a fee equal to 6.3% of net collections obtained by Consultant. If at any time during the term of this Agreement, City implements ePCR, Consultant payment will be reduced to 6.0% of net collections obtained. Consultant shall bill for Emergency Medical Services at the rates established by City Council Resolution. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing collections received by City, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on July 1, 2009 and terminate on June 30, 2012, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended for one additional two -year term upon a writing executed by the Fire Chief and the City Attorney for the City and by Consultant. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer - employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self - insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health, and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by f ' reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and /or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non -use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M -30) P.O. Box 1988 Santa Ana, California 92702 -1988 telefacsimile (714) 647 -6956 With courtesy copies to: Fire Chief City of Santa Ana 1439 S. Broadway (M -80) Santa Ana, California 92702 telefacsimile (714) 647 -5779 and City Attorney City of Santa Ana 20 Civic Center Plaza (M -29) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647 -6515 To Consultant: Wittman Enterprises 21 Blue Sky Court, Suite A Sacramento, California 95828 telefacsimile: (916) 381 -5047 A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, communication shall be effective or deemed to have been given twenty -four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by either party upon ninety (90) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Fire Chief may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 13. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 16. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall SCOPE OF SERVICES EXHIBIT A indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. c. Consultant agrees that, notwithstanding the existence of any dispute between the parties, insofar as possible under the terms of this Agreement, each party will continue to perform the obligations required of it during the continuation of any such dispute, unless enjoined or prohibited by any court. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: PATRICIA E. 1-IEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W. FLETCHER City Attorney By Laura Sheedy Assistant City Attorney CITY OF SANTA ANA: DAVID N. RE City Manager WITTMAN ENTERPRISES CORRINE WITTMAN -WONG Chief - Executive Officer Tax ID# YO 5°5 -10 D I Wittman Enterprises, LLC 3.1 SCOPE OF SERVICES Wittman Enterprises, LLC meets and will continue to exceed the City's expectations. We are dedicated to the production of quality service to the City, and demonstrate this commitment with ongoing training and updating of staff. This is accomplished by both continuous in -house cross training, and by taking advantage of outside quality training in all aspects of billing issues and customer service. We are a full service billing office and currently work with the City and multiple EMS providers. We will continue to provide the City with excellent service using our proven methods for receiving and processing PCR's, Cash Receipts, correspondence and for achieving the maximum legal reimbursement. • PCR's are date stamped and counted in double custody, They are reviewed for completeness, coded for data entry, entered, and billed within three working days. • Cash Receipts are date stamped and counted in double custody. These are posted to patient accounts within one day and notifications of these monies are reported to you via fax or email on a daily basis. • All payers whether primary or secondary are billed electronically or on paper, and followed up on until full allowed reimbursement is achieved. • Our customized invoices and letters may be designed specifically for the City. • Wittman Enterprises, LLC complies with all certifications, licenses, and laws as they pertain to this response. • We provide a multitude of reports for your financial and statistical needs. Our specialty is On- Demand reports at no additional cost and may be produced at a moments notice. • Dedicated and trained staff is immediately available to your needs. City of Santa Ana Fire Department 12 Wittman Enterprises, LLC 3.1.1 TRANSFER OF CITY INFORMATION Documents Confirmed and Screened for Com leteness Upon receipt, the City's PCR's are date stamped, counted in double custody and the number received is verified All of the City's PCR's are sent to our Data Entry Production Department where they are reviewed for completeness and coded with the appropriate level of service, payer and patient condition within 48 hours of receipt. PCR's that have social security numbers are checked for Medi -Cal eligibility by using the Medi -Cal online verification system and billed out immediately. Patient accounts with private insurance information are billed out immediately. If insurance information is not available on the PCR or by means of our research, then the patient's account is set up for private billing. A phone call to that patient is also made within 72 hours of receipt of the PCR. In order to remain true to correct billing processes, we fully audit 35% of all trips that are billed for the City at the time of data entry. Research Methods Wittman Enterprises, LLC has variety of processes and resources in place to follow -up on accounts that have inadequate billing information. These resources include but are not limited to: • Use of Zip Code /Street directories for obtaining missing /incomplete addresses • Use of Accurint.Com for tracing mail returns • Contacting EMS Division to locate missing information from Run Reports • Contacting receiving hospital for missing /incomplete billing information • Contacting patient's family members for billing or insurance information • Mailing inquiry forms to the patient. Over the past fifteen years we have established a good rapport with the city's receiving hospitals that enable us to request the following information if needed: • Insurance information including billing address, phone numbers, and member or subscriber identification number • Medicare or Medi -Cal information including — social security numbers and date of birth • Current address, phone number and employer information for the patient, • Alternate contacts or nearest relative's address or phone number Information is requested via fax or phone call to the financial office of the hospital. Requests are made weekly and come back to us in a timely manner. If no information is received, accounts are handled in accordance with the City's guidelines. City of Santa Ana Fire Department 13 Wittman Enterprises, LLC Assignment Authorization Included on all invoices and statements mailed out by Wittman Enterprises, LLC for the City is an assignment of benefit authorization that is mandatory for Medicare billing. If the signature is not obtained at the time of service by the field crews, we will release the invoice to the patient for completion. It is important to note that release of billing to Medicare is not permitted without the signature of the patient, designated guardian or witnessed declaration that the patient is not able to sign. If the field crews are not required to obtain the signature or witness the patient's inability to sign at time of service, billing and therefore payment will be significantly delayed. 3.1.2 -3.1.5 BILLING FUNCTIONS, RECORD MAINTENANCE, THIRD PARTY CLAIM, AND CROSS REFERENCE OF PATIENT ACCOUNTS Supplies and Equipment Wittman Enterprises, LLC provides all supplies, equipment, and services necessary to perform the provisions of the RFP at no additional cost to the City. Supplies, equipment, and services include but are not limited to: • All computer hardware and software necessary to perform accurately and efficiently the processes as described in this RFP • All mailing forms, billing forms, insurance forms, lien forms, and envelopes necessary to perform the billing functions • Any postage necessary to mail billing or information to patients, insurance companies, 3rd parties, and attorneys • Availability of a national toll free 800 number for patients, the City, Insurance companies, attorneys, 3rd parties to call for information or discussion of account status Electronic Billing of Claims As a matter of course, Wittman Enterprises, LLC electronically bill the City's Medicare and Medi -Cal claims resulting in payment in 14 days and 7 days respectively. California is unique in its number of Medicare and Medi -Cal HMO payers. When we receive a trip indicating Medicare or Medi -Cal coverage, we verify this information through electronic verification systems in order to be certain of billing correctly the first time. These claims are transmitted daily using ANSI, the format set forth under the HIPAA requirements. City of Santa Ana Fire Department 14 Wittman Enterprises, LLC We also electronically bill for the City, all qualified primary and secondary insurance sources, workers' compensation, health maintenance organizations, third party liability, benefit programs, and self - insurance programs. Those who do not qualify are billed on paper. Billing and Verification of Self Pay Accounts Surveys from the American Collectors Association indicate that patients are more motivated to make a payment from a telephone call rather than repeated collection notices. However, they have shown the most amount of effectiveness from a combination of these two mediums. We have found this to be true through the personal attention given to our clients and their patients. Our first call to a private account occurs immediately after data entry of the incident into the system. This "Verification" call allows us to determine if the patient has insurance or any special circumstances that will make it difficult to pay the bill in a reasonable amount of time. This early establishment of contact with the patient is very beneficial. At this point handling of the account becomes very individualized. We have found that our system of invoices, statements, delinquency notices, and individual letters in conjunction with telephone follow up has been most successful. Follow -up procedures used to elicit payment include a data file established for each patient from which information regarding the transport, billing and payment can be recorded and retrieved, and patient information can be updated. All patients may be referenced by name, date of service, incident number, run number, social security number, and insurance identification numbers. See table on page 17 for a sample bill schedule. Billing and Verification of Insurance Accounts and Third Party Pavers All insurance and third party payer information provided at the time of input is verified with phone calls. On -line access to insurance companies is utilized where offered. Our process of identifying the correct payer for a patient's claim before it is even billed has kept our percentage of incorrect billings low. Our Customer Service Representatives, in the event of incorrect insurance information, will contact hospitals, and if necessary, the patient for the corrections to that information. Bankruptcy and Litigation Accounts When notified of a personal bankruptcy all billing activity will cease. Information will be noted in the account and followed monthly. Once notification of discharge of debt is made the account is adjusted to a zero balance. In the case of probate circumstances, we will file a creditor's claim to protect the City's interests. When an account is identified as a litigation case it is flagged with a specific pay source, attorney information is added to the account, a lien is sent to the patient's attorney to be signed by both the patient and the attorney, and the patient billing is put on hold. City of Santa Ana Fire Department 15 Wittman Enterprises, LLC When requests for information are sent in, they are reviewed for compliance with HIPAA. Attorney requests can no longer be all encompassing, but must be specific. They must also include a medical release signed by the patient. The exception to this is a subpoena from the court. Follow -up on lien accounts occur every 60 days to verify that all information is current and correct, and insure that when a settlement is reached the City will receive the money due on the account in a timely manner. Our computer program g generates invoices on demand, facilitating a one -day turn around on any subpoena request that may be made. Workers' Compensation Claims Wittman Enterprises, LLC bills all workers' compensation insurers. When needed, "Green Lien" paperwork will be filled out and sent to the City for the appropriate signatures. Wittman Enterprises, LLC complies with Workers Compensations Rules and regulations. Follow -up on Open Accounts We follow up on all City accounts insuring the maximum legal reimbursement for our clients. Follow -up procedures used to elicit payment include a customized billing schedule with multiple invoices and telephone contact with the patient, the patient's responsible party, or their insurance company. A data file is established for each patient from which information regarding the transport, billing and payment can be recorded and retrieved, and patient information can be updated. As stated, under "Billing and Verification of Self Pay Accounts" page 15, we have found that our system of invoices, statements, delinquency notices, and individual letters in conjunction with telephone follow up has been most successful. Further, the software automatically updates each individual account detailing date, change, or billing function. All history and noted entries are "write protected" so no alterations can be made. In the course of billing for the City, patients are identified who do not have insurance. If these patients are unable to make one payment in full, they are offered payment arrangements that can be made on a monthly, bi- monthly, or weekly basis. A customer service representative sets up the "Time Pay" within the system and an initial letter is sent to the patient outlining the payment arrangements. The patient signs the arrangement and returns it with the first payment. Follow - up appropriate to the arrangement ensures timely payment and a statement and envelope are released after each payment is received. The minimum "Time Pay" amount accepted by the City is $50, payment arrangements with a lower amount must be submitted in writing for the City's review. All "Time Pay" accounts must be paid off within 1 year of the date of service. In addition to the "Time Pay" option Wittman Enterprises, LLC takes credit card payment on behalf of the City. Patients are able to provide credit card information through correspondence to us, over the phone or via the "Patient Portal." City Of Santa Ana Fire Department 16 Wittman Enterprises, LLC Customized Billing Forms and Follow -up Letters Wittman Enterprises, LLC has customized the private bill schedule to reflect the City's needs. The billing schedule works in conjunction with our billing program that tracks accounts receivable and assigns them to a Customer Service Representative for making follow up calls. The city's billing schedule is as follows: Send Invoice Immediately Send Statement 30 Days Send Past Due Notice 45 Days Send Final Request Notice 60 Days Invoices contain fields for specialized messages and payment instructions. We fulfill any of the City's specialized letter or message requirements. In addition to the above mailings, we provide our Customer Service Representatives letters that are appropriate to each collection situation. As part of follow -up, these letters can be scheduled to address a particular circumstance. This extends that personal touch to the collection process. Our computer program has fields filled with next of kin information, as well as employer data, so that reaching the patient or family members for additional information is successful. Payment Processing The City's payments are what we call "Dead Cash "; they are received at the City where copies are made and then forwarded to us. These payments are then posted to the proper account within one day noting the source of the payment. All charges, payments, and adjustment applied to a patient's account are retained as a permanent record of that patient's medical history. Full payments posted that result in a zero balance will require no further action. When a partial payment is made it will be posted and the balance transferred to the next appropriate pay source. For example a Medicare payment will be posted with the appropriate write downs and the patient's remaining 20% responsibility is then transferred for billing to the secondary insurance or to private billing directly to the patient. Future correspondence and follow -up is completed by a Customer Service Representative regardless of private or secondary insurance billing. City of Santa Ana Fire Department 17 Mittman Enterprises, LLC We would like to offer the City a cost saving option. Wittman Enterprises, LLC is capable of directly receiving payments on behalf of the City. This includes all correspondence, EOB's, patient letters, and requests. This would eliminate the need for City personnel to make copies of payment information and process correspondence. Payments would be posted within 1 day of receipt and the monies deposited into the City bank account. A copy of the deposit slip would be faxed or emailed to the City designated representative the same day. In compliance with Medicare rules, we will maintain deposit rights only. Refunds The accounts receivable department thoroughly researches all credit balances. We require insurance companies to request refunds in writing before we recommend release of any funds. Resolution of all credits will be completed within 30 calendar days from the date the account reflects the credit balance. Resolution may include initiation of a refund packet, recoup packet, transfer of funds, or write -off reversal. All requests are forwarded to the City for approval with detailed reports and documentation. Record Maintenance Wittman Enterprises, LLC maintains the City's records in accordance. with the generally accepted accounting principles (GAAP). Wittman Enterprises, LLC retains all records on site for seven years. Patient Care Reports and all correspondence are scanned into an electronic storage system daily. This storage system is available to all personnel insuring easy retrieval of information for a variety of purposes including requests for information by insurance companies or attorneys. The system is backed up on a daily basis to ensure it is secured. Electronic PCR's are stored as PDF files for easy retrieval. All computer - generated information is available to access at any given moment. Wittman Enterprises, LLC agrees that all account files are the property of the City and will relinquish them to the City at the termination of the contract. Toll -Free Telephone Wittman Enterprises, LLC's Customer Service Representatives are available 8:00 am to 4:30 pm for easy contact by the City's patients. Our national toll -free 800 - number has multiple lines available for patients, clients, insurance companies, attorneys, and third parties to call for information or discussion of account status. Our auto answering system moves the City's patients to a Customer Service Representative faster and more accurately than a manual system. In addition to our 800 - number, Wittman Enterprises, LLC has developed a "Patient Portal." This secure website gives patients 24 hour access to us. Patients are able to email questions and submit their insurance or payment information to us. Questions are responded to within 24 hours of receipt. City Of Santa Ana Fire Department 18 Wittman Enterprises, LLC Monitoring of Regulatory and Reimbursement Changes Wittman Enterprises, LLC sends out updates to the City regarding regulatory changes via email. Management staff is available to answer any questions that the City may have regarding these changes or any other aspects of compliance. We have at our disposal the tools necessary to provide thorough and complete rate and reimbursement analysis for the Medicare Fee Schedule Implementation Plan. These tools are updated regularly with any changes to the contents of the Medicare process so the integrity of any analysis is maintained. Training of Staff Employees are subject to an initial four week training period in which they gain knowledge of the computer system, how to gather insurance information, and how to navigate our billing software. In addition, all Customer Service Representatives have continuous customer service training. Each new employee has a 90 -day period where 100 percent of his or her work is audited for accuracy, job knowledge, and professionalism. We continuously train our staff through monthly staff meetings that cover a variety of topics from Medicare Training to Customer Service issues. Our Medicare and Medi -Cal Specialists, as well as the Revenue Assurance Team, are updated via email of any changes that may be implemented. This information is passed on through the monthly staff meeting or if needed they are passed on immediately via department memos. Management Staff meets on a weekly basis to discuss any industry or government payer changes that have occurred and the best course of action for implementation. All departments have a company manual that outlines each individual client's contacts, policies, and specific needs. It is updated on a regular basis. Our management staff participates in on- going certificated training on management and customer service. We believe that education is the key to providing excellent service to our clients. Revenue Enhancement Training Wittman Enterprises, LLC is available to provide revenue enhancement training for the City. We also offer documentation training for field personnel. This is helpful in maintaining compliance with governmental requirements and helps in the building of a partnership between the field crews and the billing office. City of Santa Ana Fire Department 19 Wittman Enterprises, LLC Undated and Current Technologv Wittman Enterprises, LLC is dedicated to maintaining and updating our technology to meet the industries needs. Our IT department is continuously on the look out for the newest software and hardware available making sure we are kept up to date with all the latest technology. Our IT department also receives ongoing updates to our billing software as it is developed by our software vendor. Internal and External Audits Wittman Enterprises, LLC keeps accurate and up -to -date records of all bills, payments, and correspondence related to billing functions to ensure a positive outcome to any audit. Wittman Enterprises, LLC is open and encourages the City and its authorized representatives to inspect and audit all data and records relating to our performance under the contract. We will be at the City's disposal during any audit procedures, insuring immediate compliance with requests for information. Routine Meetin s Wittman Enterprises, LLC is happy to meet with the City's personnel to discuss special or future needs and changes. We are available to attend meetings by teleconference or in person. Management staff is also available during regular business hours if the City should have any questions or problems that need immediate attention. The successful partnership that we have established enables us to obtain maximum legal reimbursement on all the City's accounts. Electronic Access to Records Wittman Enterprises, LLC offers computer access via a secured login that is password protected. Access is granted only to the City personnel with authorization to view such information and is strictly limited to the City's information. All patients may be referenced by name, date of service, incident and run number. Our billing software system allows for a clear and traceable audit trail for initial contact verification, billing notification and phone contact. It also, updates each individual account detailing date, change, or billing function. All history and noted entries are "write protected" so no alterations can be made. A record of all charges is maintained, a well as a complete payment history. The City has access to monitor, audit, review, examine, or study the methods, procedures, and results of our billing and collections at all times via its own "Client Portal." Access to individual patient accounts as well as standard and customized "real time" reports is available 24/7 within this website. City ojSanta Ana Fire Department 20 Wittman Enterprises, LLC Bilingual Staff Wittman Enterprises, LLC has several Spanish- speaking Customer Service Representatives in both management and non - management positions. This enables patients to have the highest quality of service available at the highest level. Wittman Enterprises, LLC also has employees who speak Mong, Chinese, and Vietnamese. If a patient speaks a language where we do not have an employee available, we utilize Language Line Services to cover any languages that cannot be provided internally. Compliance with County, State, and Federal Laws Wittman Enterprises, LLC is in complete County, State, Federal, CMS, and HIPAA regulation compliance. Yearly audits are performed to insure that our billing service remains in complete compliance, thus protecting our clients. Along with those audits, our Supervisors perform spot audits on all employees to insure their understanding and therefore their compliance with all local, state, and federal laws. Further, we ensure compliance with these laws by continually educating ourselves as to any differences that may apply. We agree to continue to abide by any applicable ordinances of the City. Compliance to HIPAA Wittman Enterprises, LLC has Privacy and Security Officers who insure that all HIPAA policies involving privacy and security are followed. They have received and offered to our clients' extensive training through seminars presented by the California Ambulance Association. We provide access to internet resources for continuing education with regard to any changes that may develop with HIPAA law. We chose the CAA for HIPAA training because that organization's attorneys, Foley and Lardner, had the greatest familiarity with California Law. HIPAA regulations require adherence to State laws if more strict. California privacy laws are among the most stringent in the nation. Therefore, we are certain that our clients are maintaining compliance with all Federal and State mandates. All employees from the Management level to clerical have received extensive training under the Minimum Necessary Rule. All Protected Health Information is secured per HIPAA requirements at the close of each business day. We have a Business Associate Agreement with the City, Government Paver Compliance Wittman Enterprises, LLC is in complete compliance with all government payers. Our Medicare compliance program has been in place for several years and is updated on a regular basis to comply with current law. David Nevins has been retained as our Medicare compliance officer since the beginning of this process. City Of Santa Ana Fire Department 21 Wittman Enterprises, LLC Mr. Nevins was formally the President of the California Ambulance Association, serves as a member of the American Ambulance Association Reimbursement Committee, and is a Former Executive Vice President of the American Ambulance Association. Our relationship with Mr. Nevins insures that we adhere to all aspects of Medicare law. He performs yearly audits to insure that our billing service remains in complete compliance, thus protecting our clients. Our internal compliance committee meets on a quarterly basis to review any Medicare issues or new information. Further, we ensure compliance with Government payers by continuingly educating ourselves through seminars provided by Medicare, Medi -Cal, and Industry Associations. Our Customer Service Supervisors monitor 10% of all telephone calls made for quality, assurance, and an additional 35% of account information changes that resulted from telephone calls and correspondence, are audited for accuracy. Calls and Correspondence Wittman Enterprises, LLC processes the City's incoming calls and correspondence in a timely, professional, and courteous manner. Our Customer Service Supervisors monitor 10% of all telephone calls made for quality assurance. An additional 35% of account information changes that resulted from telephone calls and correspondence are audited for accuracy. We pledge our continued commitment to treat the City's community with respect and compassion in the management of ambulance billing. Our personal attention to detail and gracious handling of patients has resulted in the maximum amount of reimbursement allowed while maintaining the ethics we have demonstrated in our years of service. Customer service is our number one goal at Wittman Enterprises, LLC. Claim Appeals Wittman Enterprises, LLC has become "armed" with extensive training that clarified the obligations of California insurance carriers. As a result of this training we have put into action our "Revenue Assurance Team." They know the applicable sections of the Knox Keene Act, Insurance codes, and Health and Safety codes, and quote them when demanding payment from insurance. They also file complaints with the Department of Managed Care; who govern HMO's, when an insurance company is non - compliant. This knowledge has helped us obtain correct payment from once difficult carriers such as Health Net, one of the largest in California. They also appeal claims, demand payment, with interest if applicable, from any non - compliant insurance company. Workers' Comp and insurance companies are challenged when claims are denied or underpaid. Denials are not simply "accepted." City of Santa Ana Fire Department 22 Wittman Enterprises, LLC Our Medicare and Medi -Cal Specialists process all denials and appeals. These specialists receive extensive training in all aspects of Medicare and Medi -Cal billing. Our Medicare specialists are versed in federal law and in the implementation of the Medicare fee schedule. Our Medi -Cal specialists have expertise when billing the City's many Medi -Cal HMO's the largest of which is Cal- Optima. Cal- Optima is notorious for underpaying claims. Our specialist appeal on a regular basis underpayments such as $16.07 for EKG's or $9.88 for oxygen. With the implementation of a 10% reduction in Medi -Cal reimbursement every penny counts and appeals are necessary. Cross Over Claims Wittman Enterprises, LLC currently and will continue to bill cross -over and balance billings to all qualified secondary insurances and private pay accounts. Medi -Medi patient balances are written down as required by Medi -Cal statutes. Backup Billing Procedures Wittman Enterprises, LLC computer hardware consist of a redundant Raid Ten Array Network Attached Storage, running on two Dell 6850 Quad processing duo core servers on Windows 2003 Advanced Server in active /passive cluster mode. In addition, our Dell LTO 3 Auto Loading tape backup device uses Veritas Backup Exec Software. All files are backed up nightly and the tapes are stored off site. We utilize Rescue Net Billing by ZOLL Data Systems. It is a Windows based software system and is commercially available. In the event of a catastrophic event the software is readily available for us to replace through ZOLL Data Systems. As an added precaution all backup and system programs are kept offsite. City of Santa Ana Fire Department 23 Wittman Enterprises, LLC 3.1.6 Reports Wittman Enterprises, LLC provides financial, statistical and fiscal reports of all billing pursuant to Generally Accepted Accounting Principles (GAAP) on a monthly, quarterly, and annual basis, or as requested by the City. Accumulated revenue reports for the City are sent on a monthly basis. Our reports are detailed and easy to read. Reports can be provided hard copy, emailed, or available on our website for retrieval. Sample Reports The following is a sampling of the reports we provide to the City along with some that can be requested at a moments notice. These reports cover our ability to account for detailed Medicare, Medi -Cal, Membership, and Bad Debt write offs of any type and to track revenue by period: Ticket Survey Ticket Survey — Detail or Summary can be run by date of service, payer or patient or combination there of. Ticket Surveys are used to provide information such as number of account inputted into the system in a given month and payer mix. This information can be used to verify that all tickets sent have been received and for projection of revenue. Year to Date Revenue and Management Summary Reports The Year to Date Report provides a snapshot of the last twelve months at any given time. This report offers totals in all categories. It also reflects the ongoing collection rate, both gross and net, for the twelve -month period. The Management Summary report is run by fiscal year. It provides an accounting by financial class of total trips and dollars billed each month, with a cumulative year -to -date tracking. It also provides an accounting of the dollars received each month by financial class with a cumulative year -to -date tracking. Re and Report The refund report lists patient name, trip date, run number, incident number, and the amount to be refunded. Monthly Payment Listing The Monthly Cash Receipts Journal lists patient name, payer, date of service, payment, contractual write downs, write -off, refunds, and revenue adjustments by deposit date for each patient. City of Santa Ana Fire Department 24 Wittman Enterprises, LLC Activi Summary Will track account by individual payer including account with a payment plan and total amount collected and balance remaining. Agin A/R Aging — Detail or Summary by Trip Date (date of service), Patient, or Payer. The report can be customized to track a specific payer or payers and date ranges Adhoc Re orts On- Demand reports are our specialty, at no additional charge.. Our billing software collects and tracks a number of data elements whether input or electronically downloaded. Such reports are readily available on -line for the City's review and can contain Month End and "Real Time" information. City of Santa Ana Fire Department 25 Wittman Enterprises, LLC 3.1.7 Special Accounts Discounts, Hardship, and Other Policies The City's policies are well established and apply to all residents and business owners within the City limits. The City does not offer discounting of any kind. All hardship requests are sent with the appropriate substantiating documentation to the City for review. We are then notified of the decision and forward that decision on to the patient. All procedures are listed in your company specifics and we will continue to follow all guidelines that have been established. Subscription Program The City of Santa Ana has a Paramedic Membership program. All accounts are verified for membership prior to data entry. Verification of a patient's membership is done 2 ways. If the membership is paid through the water bill we call the City of Santa Ana Water Department and using the patient's address, date of service, and the name on that the water bill we verify paramedic coverage and ask for the membership #. If the patient pays for the membership on an annual basis we check the Paramedic Membership book the City provides to us. If the patient is not on the list but insist that they are on the yearly program we call the City to verify membership. Patient accounts that do not have insurance information listed are researched through a phone call to the patient, hospital contact or an information letter sent to the patient. Once all insurance payments have been received, we do not bill the patient or call them, the balance is written off to the membership program. If the member does not have any /or other insurance, the balance is written off to the membership program. If the patient was not a valid member on the date of service, we continue to bill the patient accordingly. Dispute Resolution The resolution of disputes is performed in accordance with the City and HIPAA guidelines. Wittman Enterprises, LLC has developed and will maintain a good rapport with the City's staff, working closely with them to find a quick and equitable resolution to all patient disputes. While we receive and make over 10,000 calls per week our Customer Service Representatives at Wittman Enterprises, LLC are aware that we represent the City's interest when responding to inquiries from patients, insurance companies, attorneys and others. Customer Service Representatives process all incoming mail, insurance EOB's, and patient disputes. We are often able to dispel any concerns or disputes regarding charges without involving City personnel, however, we immediately notify the City of any patient care complaints. City OfEanta Ana Fire Department 33 Wittman Enterprises, LLC 3.1.8 Delinquent Accounts All accounts that are being written off to collections are sent electronically to the City's collection agency. Accounts can be pulled from collections within 30 days of referral. All collection questions are referred to the City's collection agency. Before an account can be recommended for referral the following procedures must have been performed: • Bill Schedule has been completed • Utilization of all appropriate follow -up letters • Alternate contacts have been used • Attempts to locate correct address and telephone number with the Haines Directory, White Pages.com and Accurint.Com • Hospital contacted for better information • Medi -Cal eligibility re- verified City of Santa Ana Fire Department 34 Wittman Enterprises, LLC PRICING The City has realized the highest possible revenue from our efforts. We are pleased to be a part of the City's success and we wish to continue as your billing agent. We believe we have a strong foundation for a mutually satisfactory long -term relationship. The added improvements to our knowledge and technical abilities have enhanced our ability to continue to provide and exceed the excellent service the City has come to expect. We offer our billing services at the following rates: 6.3% - Paper PCR's 6.0% - If at any time during the contract the City obtains ePCR capabilities Other agencies may come in with a lower fee, but we ask the City to consider that it is our "personal attention" that creates the increased revenue; and since we have a proven record of beating the competition by at least 10% on collections, we believe the City will continue to net more income with our service. We strongly encourage the City to contact our references. Once you have you will be assured that what we state in our response is not just `fluff. " What we say we do is what we actually do. City of Santa Ana Fire Department 35 canto. CERTIFICATE OF LIABILITY INSURANCE OPID DATE(MMJDD /YYYY) PRODUCER WITTM -1 06/23/08 THIS CERTIFICATE IS �u AO A MATTER Intercare Insurance Solutions ONLY AND CONFERS NO RIGHTS UPON T EOCERTIFFICATEION 3010 Lava Ridge Ct. , Ste 110 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Roseville CA 95661 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Phone :916- 677 -2100 Fax:916- 677 -2473 -INSURED - - - -- -- - -- INSURERS AFFORDING COVERAGE NAIC # INSURER A: Republic Indemnity Ins CO INSURER B: POtBoxn26911prises LLC INSURER Sacramento CA 95826 INSURER COVERAGES NSURER E: -- - - -_ -- 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. 7GEN7ERAIL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIABILITY DATE MM /DD/YY DATE MM /DD /YY LIMITS MERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS MADE�� QCCUR PREMISES (Ea occurence) I $ MED EXP (An on y e person) $ GEN'L AGGREGATE LIMIT APPLIES PER POLICY PRO- JECT LOC AUTOMOBILE LIABILITY r ANY AUTO � ALL OWNED AUTOS I SCHEDULED AUTOS HIRED AUTOS —I NON -OWNED AUTOS 1 GARAGE LIABILITY ANY AUTO I— —I EXCESS /UMBRELLA LIABILITY OCCUR I ,. - CLAIMS MADE DEDUCTIBLE RETENTION $ j WORKERS COMPENSATION AND A EMPLOYERS' LIABILITY ANY ICEWMEMBER'PARTNER, DxECUrIVE 16620404 If yes, describe under I SPECIAL PROVISIONS below IDESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXC CERTIFICATE HOLDER The Ciity of Santa Ana 1439 Broadway Santa Ana CA 92701 -- �4uu Iluts) �1 TO FO City Attorney NS ADDED BY ENDOR PERSONAL & ADV INJURY $ GENERALAGGREGATE $ PRODUCTS - COMP /OP AGG $ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ AUTO ONLY - EA ACCIDENT $ - -- OTHER THAN EA ACC I ._. _ $ - - AUTO ONLY AGG - -- - -- $ EACH OCCURRENCE $ AGGREGATE - �— i$ I --I I U17 LIMI I S )—. 1 ER L— 07/01/08 07/01/09 E.L EACHACCIDENT- - - s 100000.0_ EL DISEASE EA FNIPL r- $ 1000000 I OYE_� - - -- 1--� ---------------- .�---- - - -- -0 El DISEASE POLICY LIMIT i$ .100000 MENT / SPECIAL PROVISIONS SANTANA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER N MED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR ABILITY F ANY�ND L, E INSURER, ITS AGENTS OR REPRESENTATIVES. n Kristen ACgRP CORPORATION 1988 A'vV![� WITTENT -01 MAMI n" CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD /YYYY) PRODUCER 916 231 -1741 7/9/2008 ( ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Wells Fargo of California Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CA DOI LIC #0352275 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 11017 Cobblerock Drive, Suite 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Rancho Cordova, CA 95670 - - - -- INSURERS AFFORDING COVERAGE RED INSU Wittman Enterprises Lic - - - -- - — NAIC # P. O. Box 269110 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ICertificate Holder is named as additional insured per attached SS 04 49 05 93. Subject to 10 day notice of cancellation for non - payment of premium. APPROVED AS TO FORM N «� L ft OF CFFTIFIC ATE TE HOLDER Laura St Lt 5 dy CANCELLATION City of Santa Ana Assistant City Attorney SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1439 Broadway DATE THEREOF, THE ISSUING INSURER WILLXN)6)["X)I'OIiMAIL 30 Santa Ana, CA 92701- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ei�Xl�(l�(j((j(��j( IAUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 INSURER A Hartford Casualty Insurance Company Sacramento, CA 95826 -9110 INSURER B Executive Risk Indemnity, Inc. — LER _ COVERAGES - - -- 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 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS BY PAID CLAIMS. OF SUCH I INS LTR R POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION - - - T / - - - - - GENERAL LIABILITY / Y LIMITS A X ��` COMMERCIAL GENERAL LIABILITY o7SBAAT649O EACH OCCURRENCE 7/1/2008 711/2009 2,000,00 CLAIMS MADE J � OCCUR PREMISES Ea occurence $ 300,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 2,000,001 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,00) X POLICY PRO- T LOC PRODUCTS - COMP /OP AGG $ 4,000,0 OI AUTOMOBILE LIABILITY A ANY AUTO 57SBAAT6490 SINGLE LIMIT $ 7/1/2008 7/1/2009 Ea accident) 2,000,00( ALL ALL OWNED AUTOS _ SCHEDULED AUTOS BODILY INJURY _ X HIRED AUTOS (Per person) $ Ix I NON -OWNED AUTOS I BODILY - INJURY (Per accident) $ ----- --_ -- � - - -- PROPERTY DAMAGE GARAGE LIABILITY (Per accident) $ ANY A �� UTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ EXCESS /UMBRELLA LIABILITY AUTO ONLY AGG $ occuR A CLAIMS MADE 57SBAAT6490 EACH OCCURRENCE $ 7/1/2008 7/1/2009 2,000,00 �t AGGREGATE $ 2,000,00 DEDUCTIBLE $ _ X RETENTION $ 10,000 $ _ WORKERS COMPENSATION AND-- - " °—'I - - EMPLOYERS' LIABILITY WC SIITATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE TORY LMTS ER OFFICER/MEMBER EXCLUDED? yes, describe under E.L. EACH ACCIDENT $ S S PECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE $ OTHER E.L. DISEASE - POLICY LIMIT $ B Errors & Omissions 81716616 7/1/2008 7/1/2009 Per Aggregate/Per Claim 1- DOO_Dnn DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ICertificate Holder is named as additional insured per attached SS 04 49 05 93. Subject to 10 day notice of cancellation for non - payment of premium. APPROVED AS TO FORM N «� L ft OF CFFTIFIC ATE TE HOLDER Laura St Lt 5 dy CANCELLATION City of Santa Ana Assistant City Attorney SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1439 Broadway DATE THEREOF, THE ISSUING INSURER WILLXN)6)["X)I'OIiMAIL 30 Santa Ana, CA 92701- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ei�Xl�(l�(j((j(��j( IAUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) WITTENT -01 MAMI POLICY NUMBER: 57SBAAT6490 NAMED INSURED: WITTMAN ENTERPRISES, LLC COMPANY NAME: HARTFORD CASUALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED -- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM Name of Person or Organization: SCHEDULE CITY OF SANTA ANA, ITS OFFICERS, AGENTS, REPRESENTATIVES, AND EMPLOYEES 1439 BROADWAY ALL CALIFORNIA OPERATIONS SANTA ANA, CA 92701 Who is an insured in the BUSINESS LIABILITY COVEAGE FORM is amended to included as an insured the person or organization shown in the Declarations, but only with respect to liability arising out of the operation of the named insured. For Losses covered under the BUSINESS LIABILILTY COVERAGE of this policy this insurance is primary to other valid and collectible insurance, which is available to the person or organization shown in the Declarations as an Additional Insured. SS 04 49 05 93 Printed in U.S.A. (NS) Copyright, Hartford Fire Insurance Company, 1993 ~ INSURANCE NOT REQUIRED WORK MAY PROCEED CLERK OF COUNCIL HIPAA WISINESS ASSOCIATE AGREEMENT This Agreement ( "Agreement ") is entered into by and between Wittman Enterprises, LLC ("Business Associate ") and City of Santa Ana Fire Department ( "Covered f?ntity "). RECITALS WHEREAS, Business Associate performs functions, activities, or services fix, or on behalf of Covered Entity, and Business Associate receives, has access to or creates Ilealth Information in order to perform such functions, activities or services; WHEREAS, Covered Entity is subject to the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated there under ( "11111AA "), including but not limited to, the Standards for Privacy of Individually Identifiable Health Information, 45 Code of Federal Regulations Parts 160 and 164; and WHEREAS, HIPAA requires Covered Entity to enter into a contract with Business Associate to provide for the protection of the privacy and security of Health Information, and HIPAA prohibits the disclosure to or use of Health Information by Business Associate if such a contract is not in place. AGREEMENT NOW, THEREFORE, in consideration of the foregoing, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties agree as follows: ARTICLE 1 DEFINITIONS 1.1 "Disclose" and "Disclosure" mean, with respect to Health Information, the release, transfer, provision of access to, or divulging in any other manner of Health Information outside Business Associate's internal operations or to other than its employees. 1.2 "Health Information" means information that (a) relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual; (b) identifies the individual (or for which there is a reasonable basis for believing that the information can be used to identify the individual); and (c) is received by Business Associate from or on behalf of Covered Entity, or is created by Business Associate, or is made accessible to Business Associate by Covered Entity. 1.3 "Privacy Regulations" means the Standards for Privacy of Covered Individually Identifiable Health Information, 45 Code of Federal Regulations Parts 160 and 164, promulgated under HIPAA. 1.4 "Services" means the services provided by Business Associate pursuant to the Underlying Agreement(s), or if no such agreement(s) are in effect, the services Business Associate performs with respect to the Covered Entity. 1.5 "Underlying Agreement" means the services agreement executed by the Covered Entity and Business Associate, if any. 1.6 "Use" or "Uses" mean, with respect to Health Information, the sharing, employment, application, utilization, examination or analysis of such Health Information within Business Associate's internal operations. ARTICLE II OBLIGATIONS OF BUSINESS ASSOCIATE, 2.1 Initial Effective Date of Performance. The obligations created under this Agreement shall become effective on April 14, 2001 2.2 Permitted Uses and Disclosures of Health Information. Business Associate is authorized to and shall: a. Use and Disclose Health Information as necessary to perform Services for, or on behalf of Covered Entity: b. Use Health Information to create aggregated or de- identified information (in accordance with the requirements of the Privacy Regulations); C. Use or Disclose Health Information (including aggregated or de- identified information) as otherwise directed by Covered Entity provided that Covered Entity shall not request Business Associate to Use or Disclose Health Information in a manner that would not be permissible if done by Covered Entity. Business Associate shall not Use Health Information for any other purpose, except that if necessary, Business Associate may Use Health Information for the proper management and administration of Business Associate or to carry out its legal responsibilities; provided that any Use or Disclosure described herein will not violate the Privacy Regulations or California law if done by Covered Entity. Except as otherwise limited in this Agreement, Business Associate may Disclose Health Information for the proper management and administration of the Business Associate, provided that with respect to any such Disclosure either (a) the Disclosure is required by law (within the meaning of the Privacy Regulations) or (b) the Disclosure would not otherwise violate California law and Business Associate obtains reasonable written assurances from the person to whom the information is to be Disclosed that such person will hold the information in confidence and will not Use or further Disclose such information except as required by law or for the purpose(s) for which it was Disclosed by Business Associate to such person, and that such person will notify Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached. 2.3 Adequate Safeguards for Health Information. Business Associate warrants that it shall implement and maintain appropriate safeguards to prevent the Use or Disclosure of Health Information in any manner other than as permitted by this Agreement. 2.4 Mitigation. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a Use or Disclosure of Health Information by Business Associate in violation of the requirements of this Agreement. 2.5 Reporting Non - Permitted Use or Disclosure. Business Associate shall report to Covered Entity each Use or Disclosure that is made by Business Associate, its employees, representatives, agents or subcontractors that is not specifically permitted by this Agreement of which Business Associate becomes aware. The initial report shall be made by telephone call to the Covered Entity within forty-eight (48) hours from the time the Business Associate becomes aware of the non - permitted Use or Disclosure, followed by a written report to covered Entity no later than five (5) days from the date the Business Associate becomes aware of the non - permitted Use or Disclosure. 2.6 Availability of Internal Practices Books and Records. Business Associate agrees to make its internal practices, books and records relating to the Use and Disclosure of Health Information available to the Secretary of the U.S. Department of Health and Human Services ( "Secretary"), for purposes of determining Covered Entity's compliance with the Privacy Regulations. 2.7 Access to and Amendment of Health Information. Business Associate shall, to the extent Covered Entity determines that any Health Information constitutes a "designated record set" under the Privacy Regulations, (a) make the Health Information specified by Covered Entity available to Covered Entity or to the individual(s) identified by Covered Entity as being entitled to access and copy that Health Information, and (b) make any amendments to Health Information that are requested by Covered Entity. Business Associate shall provide such access and make such amendments within the time and in the manner specified by Covered Entity. 2.8 Accounting of Disclosures. Upon Covered Entity's request, Business Associate shall provide to Covered Entity an accounting of each Disclosure of Health Information made by Business Associate or its employees, agents, representatives or subcontractors as required by the Privacy Regulations. For each Disclosure that requires an accounting under this Section 2.8, Business Associate shall track the information required by the Privacy Regulations, and shall securely maintain the information for six (6) years from the date of the Disclosure. 2.9 Use of Subcontractors and Agents. Business Associate shall require each of its agents and subcontractors that receive Health Information from Business Associate to execute a written agreement obligating the agent or subcontractor to comply with all the terms of this Agreement with respect to such Health Information. ARTICLE 111 OBLIGATIONS OF COVERED ENTITY 3.1 Privacy Notice. Covered Entity shall notify Business Associate of any limitation(s) in Covered Entity's notice of privacy practices to the extent such limitation(s) may affect Business Associate's Use or Disclosure of Health Information. ARTICLE IV TERM AND TERMINATION 4.1 Term. Subject to the provisions of Sections 4.2 and 4.3, the term of this Agreement shall be the term of the Underlying Agreement(s). 4.2 Termination for Cause. Upon Covered Entity's knowledge of a material breach of this Agreement by the Business Associate, Covered Entity shall either: a. notify Business Associate of the breach in writing, and provide an opportunity to cure the breach or end the violation within ten (10) business days of such notification; provided that if Business Associate fails to cure the breach or end the violation within such time period to the satisfaction of Covered Entity, Covered Entity shall have the right to immediately terminate this Agreement and the Underlying Agreement(s) upon written notice to Business Associate; b. upon written notice to Business Associate, immediately terminate this Agreement and the Underlying Agreement(s) if Covered Entity determines that such breach cannot be cured; or C. if Covered Entity determines that neither termination nor cure is feasible, the Covered Entity shall report the violation to the Secretary. 4.3 Termination for Breach of Section 5.2. Covered Entity may terminate the Underlying Agreement(s) and this Agreement upon thirty (30) days written notice in the event (a) Business Associate does not promptly enter into negotiations to amend this Agreement when requested by Covered Entity pursuant to Section 5.2 or (b) Business Associate does not enter into an amendment to this Agreement providing assurances regarding the safeguarding of Health Information that the Covered Entity, in its sole discretion, deems sufficient to satisfy the standards and requirements of HIPAA. 4.4 Disposition of Health Information Upon Termination or Expiration. Upon termination or expiration of this Agreement, Business Associate shall either return or destroy, in Covered Entity's sole discretion and in accordance with any instructions by Covered Entity, all Health Information in the possession or control of Business Associate and its agents and subcontractors. In such event, Business Associate shall retain no copies of such Health Information. However, if the Business Associate determines that neither return nor destruction of Health Information is feasible, Business Associate shall notify Covered Entity of the conditions that make return or destruction infeasible, and may retain Health Information provided that Business Associate (a) continues to comply with the provisions of this Agreement for as long as it retains Health Information, and (b) further limits Uses and Disclosures of Health Information to those purposes that make the return or destruction of Health Information infeasible. ARTICLE V MISCELLANEOUS 5.1 Indemnification. Notwithstanding anything to the contrary in the Underlying Agreement(s), at Business Associate's expense, Business Associate agrees to indemnify, defend and hold harmless Covered Entity and Covered Entity's employees, directors, officers, subcontractors or agents (the "Indemnities ") against all damages, losses, lost profits, fines, penalties, costs or expenses (including reasonable attorneys' fees) and all liability to third parties arising from any material breach of this Agreement by Business Associate or its employees, directors, officers, subcontractors, agents or other members of Business Associate's workforce. Business Associate's obligation to indemnify the Indemnities shall survive the expiration or termination of this Agreement for any reason. 5.2 Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to electronic data security and privacy are rapidly evolving and that amendment of this Agreement may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA and other applicable laws relating to the security or confidentiality of Health Information. The parties understand and agree that Covered Entity must receive satisfactory written assurance from Business Associate that Business Associate will adequately safeguard all Health Information that it receives or creates on behalf of Covered Entity. Upon Covered Entity's request, Business Associate agrees to promptly enter into negotiations with Covered Entity, concerning the terms of any amendment to this Agreement embodying written assurances consistent with the standards and requirements of HIPAA or other applicable laws. 5.3 Relationship to Underlying Agreement(s) Provisions. In the event that a provision of this Agreement is contrary to a provision of an Underlying Agreement(s), the provision of this Agreement shall control. Otherwise, this Agreement shall be construed under, and in accordance with, the terms of such Underlying Agreement(s), and shall be considered an amendment of and supplement to such Underlying Agreement(s). 5.4 Modification of Agreement. No alteration, amendment, or modification of the terms of this Agreement shall be valid or effective unless in writing and signed by Business Associate and Covered Entity. 5.5 Non - Waiver. A failure of any party to enforce at any time any term, provision or condition of this Agreement, or to exercise any right or option herein, shall in no way operate as a waiver thereof, nor shall any single or partial exercise preclude any other right or option herein. In no way whatsoever shall a waiver of any term, provision or condition of this Agreement be valid unless in writing, signed by the waiving party, and only to the extent set forth in such writing. 5.6 Agreement Drafted By All Parties. This Agreement is the result of arm's length negotiations between the parties and shall be construed to have been drafted by all parties such that any ambiguities in this Agreement shall not be construed against either party. 5.7 Sever ability. If any provision of this Agreement is found to be invalid or unenforceable by any court, such provision shall be ineffective only to the extent that it is in contravention of applicable laws without invalidating the remaining provisions hereof. 5.8 Section Headings. The section headings contained herein are for convenience in reference and are not intended to define or limit the scope of any provision of this Agreement. 5.9 No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement. 5.10 Counterparts. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, and will become effective and binding upon the parties as of the effective date at such time as all the signatories hereto have signed a counterpart of this Agreement. 5.1 1 Notices. Any notices required or permitted to be given hereunder by either party to the other shall be given in writing: (1) by personal delivery; (2) by electronic facsimile with confirmation sent by United States first class registered or certified mail, postage prepaid, return receipt requested; (3) by bonded courier or by a nationally recognized overnight delivery service; or (4) by United States first class registered or certified mail, postage prepaid, return receipt requested, in each case, addressed to: If to Business Associate: Wittman Enterprises, LLC 21 Blue Sky Court Sacramento, CA 95828 Attn: Privacy Officer If to Covered Entity: City of Santa Ana Fire Department P.O. Box 1988 -M 13 Santa Ana, CA 92702 Attn: Jeff Talmage or to such other addresses as the parties may request in writing by notice given pursuant to this Section 5.12. Notices shall be deemed received on the earliest of personal delivery; upon delivery by electronic facsimile with confirmation from the transmitting machine that the transmission was completed; twenty-four (24) hours following deposit with a bonded courier or overnight delivery service; or seventy-two (72) hours following deposit in the U.S. Mail as required herein. 5.12 Applicable Law and Venue. This Agreement shall be governed by and construed in accordance with the internal laws of the State of California (without regard to principles of conflicts of laws). The parties agree that all actions or proceedings arising in connection with this Agreement shall be tried and litigated exclusively in the state or federal (if permitted by law and a party elects to file an action in federal court) courts located in Orange County. This choice of venue is intended by the parties to be mandatory and not permissive in nature, and to preclude the possibility of litigation between the parties with respect to, or arising out of, this Agreement in any jurisdiction other than that specified in this Section 5.12. Each party waives any right it may have to assert the doctrine of forum non - convenience or similar doctrine or to object to venue with respect to any proceeding brought in accordance with this Section 5.12. 5.13 Interpretation. Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply with the Privacy Regulations. IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective as of the date stated above. By: Printe Title: Dated: BUSINESS ASSOCIATE By: Printed Name: Dona Wittman Title: President Dated: Article VI Amendment to Business Associate Agreement This agreement serves as an Amendment to the existing Business Associate Agreement (B.A.A.) between Wittman Enterprises, LLC (B.A.), and The City of Santa fire Depa,en,-nt itIA, (Covered Entity) with an original date of 04/01/2003 . The parties acknowledge that acceptance of this Amendment by the Business Associate is an essential requisite to providing its contracted services to The City of Santa Fi e- BePWMT9M /one 1. This Amendment is incorporated into the existing Business Associate Agreement between the parties and is an integral part of that agreement. 2. This Amendment shall be effective May 1, 2009 as long as the existing B.A. Agreement has not been terminated. "Security Rules" I. This Amendment is executed pursuant to the requirements of the Security Regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (Security Rule) found at 45 CPR Part 164. 2. Wittman Enterprises, LLC (B.A.) agrees to assume the following obligations regarding electronic Protected Health Information (e -PHI): a. B.A. agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of e -PHI that it creates, receives, maintains, or transmits on behalf of The City of Santa rife- DepeOntent Arq , if any. b. B.A. will ensure that any agent, including a subcontractor, to whom it provides e -PHI that was created, received, maintained, or transmitted on behalf of The City of Santa Fire Department ' agrees to implement reasonable and appropriate safeguards to protect the confidentiality, security, and integrity of e -PHI. c. B.A. agrees to alert The City of Santa F*@4;apa4#;Ra f V)c, of any security incident (as defined by HIPAA Security Rule) of which it becomes aware and the steps it has taken to mitigate any potential security compromise that may have occurred and to provide a report to The City of Santa Fire Department of any loss of data or other information system compromise as a result of the incident. d. B.A. authorizes termination of B.A. Agreement if The City of Santa Fire^9epeNment/} 14, reasonably determines that B.A. has violated a material term of this Amendment. "Privacy Rules" 1. This Amendment is executed pursuant to the requirements of the American Recovery and Reinvestment Act of 2009; Title XIII of the ARRA; Health information Technology for Economic and Clinical Health Act Subtitle D section 13400 — 13424. 2. Wittman Enterprises, LLC (B.A.) agrees to assume the following obligations of the "ARRA ": a. B.A. agrees to a patient's right to an accounting of all disclosures from an electronic health record (HER) b. B.A. agrees to a patient's right to request restrictions on the use of PHI when the service is paid for out of pocket and a request is made not to bill their health insurance c. B.A. agrees to a patient's right to obtain their PHI in an electronic format if it is stored in that manner d. B.A. agrees to notify Covered Entity when a breach of PHI is discovered e. B.A. agrees to the obligation that it must report any non compliance of HIPAA by the Covered Entity f. B.A. authorizes termination of the Business Associate Agreement if The City of Santa Rm- "Pau«—t A,,c, reasonably determines that the B.A. has violated a material term of this Amendment. "Red Flat Rules" 1. This Amendment is executed pursuant to the requirements of the Identity Theft Red Flag Rules promulgated under the Fair and Accurate Credit Transactions of 2003( "Red Flag Rules ") found at 16 C.F. R Part 681. 2. Wittman Enterprises, LLC (B.A.) agrees to assume the following obligations of the "Red Flag Rules ": a. B.A. agrees to ensure that its activities for The City of Santa Foment tjnta are conducted in accordance with reasonable policies and procedures designed to detect, prevent, and mitigate the risk of identity theft. b. B.A. agrees to have in place policies and procedures to detect relevant "Red Flags" that may arise in the performance of services on behalf of The City of Santa Fire- BepeMwent c. B.A. agrees that it has received a copy of the The City of Santa Fire -Bepa eHtA- Identity Theft Prevention Program and that it will take all steps necessary to comply with the policies and procedures therein. d. B.A. will ensure that any agent or third party, who performs services on its behalf in connection with The City of Santa Ziw4Be¢ectiRe t FchQ covered accounts, including a subcontractor, agrees to implement reasonable policies and procedures designed to detect, prevent, and mitigate the risk of identity theft. e. B.A. agrees to alert The City of Santa Fi" OW44 went of any "Red Flag" incidents (as defined by the "Red Flag Rules ") of which is becomes aware, and the steps it has taken to mitigate any potential security compromise that may have occurred, and provide a report to The City of Santa Firweepariment ` fLtz of any threat of identity theft as a result of the incident. f. B.A. authorizes termination of the Business Associate Agreement if The City of Santa Fire-eeparrm reasonably determines that the B.A. has violated a material term of this Amendment. Agreed to on this day of T THE CITY OF ��`i <<SANTA AN //A,, � Print: �lt"ey �J ,vtvtGtt'TW� By: rA . n Title:�Syt ����✓ 2009 Wittman Enterprises, LLC Corinne Wittman W Date: V - —' 0- -r? � )i J — /-' —L)/ APPROVED AS TO FORM Laura Sti t Sheedy Assistant City Attorney v — wn itry I -ui ACORU. CERTIFICATE OF LIABILITY INSURANCE DATE NSR 718/2009) PRODUCE _do. '1e1`l81 (irl' ; ((1*A A741 Wells Fl Ingo of Catifbrriia Insurance Services Inc. 11017 Cobblerock Drive, Suite 100 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. INSURERS AFFORDING COVERAGE NAIC # iji�hc( �Jord�, C50 -� INSURED Wittman Enterprises, LLC INSURER A: Hartford Casualty Insurance Company 29424 INSURER B: National Fire Insurance Company of Hartford 20478 PO Box 269110 EACH OCCURRENCE INSURER c: Executive Risk Indemnity 35181 INSURER D: r Sacramento, CA 95826 lA \ICSw��c. INSURER E: 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. INSR LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM D Y POLICY EXPIRATION DATE MM D Y ) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR 57SBAAT6490 07/01/2009 07/01/2010 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED $ 300.000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT LOC PRODUCTS - COMP /OP AGG $ 4,000,000 B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS B4012487490 07/01/2009 07/01/2010 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ ' GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ A EXCESS /UMBRELLA LIABILITY 7X OCCUR FI CLAIMS MADE DEDUCTIBLE X RETENTION $ 10,000 57SBAAT6490 07/01/2009 07/01/2010 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AIJY PROPRIETOR/PARTNER/EXECU. IVE OFFICER /MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below OTHER Prof Liability 81716616 07/01/2009 07/01/2010 WC STATU- OTH- TORY LIMIT E.L. EACH ACCIDENT $ -- E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ $1,000,000/$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS APPJk01Vqh1J FORM Certificate holder named additional insured per attached form SS0008 04/05, pages 18 -20. �, " 10 day notice applies if cancelled for non - payment of premium. y % Laura A ,. 5;icedy Assista� City Attorney i`C DTI Cl/�ATG LJf�I nrr • •. -. _ -.• .-. .. .. - .. _ City of Santa Ana 14139 Broadway :?anta Ana, CA 92701 ACORD 25 (2001!e31 i ns 9 661228 {�,/, /��J 9 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION -" ` ��� • TIHE CERTIFICATE HOLDER NAMED T E'FfT,MAIl7Fzq'pgS WRITTEN I I�RJ�t41X�XC74TJOLtJOBC Em6' B�ORXx�X1KNXNl4NDk�lN�iB�SOBBRSXRXX�BI�B (fiRxx AUTHORIZED REPRESENTATIVE W AL UKU GvKVVKAIIVN 1958 (This certificate replaces certifcate# 625376 issued on 6/26/2009) IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement L on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S (2001/08) 2 of 2 iiQa4r jrnnAn4 enAe BUSINESS LIABILITY COVERAGE FORM F. OPTIONAL ADDITIONAL INSURED COVERAGES It listed or shown as applicable in the Declarations, one or more of the following Optional Additional Insured Coverages also apply. When any of these Optional Additional Insured Coverages apply, Paragraph 6. (Additional Insureds When Required by Written Contract, Written Agreement or Permit) of Section C., Who Is An Insured, does not apply to the person or organization shown in the Declarations. These coverages are subject to the terms and conditions applicable to Business Liability Coverage in this policy, except as provided below, 1. Additional Insured - Designated Person Or Organization WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations, but only with respect to liability for "bodily injury "', `property damage" or .'personal and advertising injury" caused, in :whole or in part. Ui your acts or omissions or the acts or omissions of those acting on your behalf: a. In the performancc., of your ongoing operations: or b. In connection with Your Premises owned by or rented to you. 2. Additional Insured - Managers Or Lessors Of Promises a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or organi7ation(s) shown in the DeclaraJons as an Additional Insured - Designated Person Or Organization; but only with respect to liability arising out of the ownership, maintenance or use of that part of the Premises leased to You and shown in the Declarations, b. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that Premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. Page 18 of 24 3. Additional Insured - Grantor Of Franchise WHO IS AN INSURED under Section C, is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations as an Additional Insured - Grantor Of Franchise, but only with respect to their liability as grantor of franchise to you, 4. Additional Insured - Lessor Of Leased Equipment a. WHO IS AN INSURED Linder Section C. is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations as an Additional Insured — Lessor of Leased Equipment, but only with respect tc liability for "bodily injury", "property damage' or "personal and advertising injury' caused, in whole or in part, by your maintenance. operation or use of equipment leased to you by such person(s) or organization(s), b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after you cease to lease that equipment. 5. Additional Insured - Owners Or Other Interests From Whom Land Has Been Leased a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or orqanization(s) shown in the Declarations as an Additional Insured — Owners Or Other Interests From Whom Land Has Been Leased, but only with respect to liability arising out of the ownership, maintenance or use of that part of the land leased to you and shown in the Declarations, b. With respect to the insurances afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to (1) Any "occurrence" that takes place after you cease to lease that land: or (2) Structural alterations, new construction or demolition operations Performed by or on behalf of such person or organization, Additional Insured - State Or Political Subdivision — Permits a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the state or political subdivision shown in the. Declarations as an Additional Form SS 00 08 04 05 Insured - State Or Political Subdivision - Permits, but only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. b. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to, (1) "Bodily injury", "properly damage" or "personal and advertising injury" arising out of operations Performed for the state or municipality; or (2) "Bodily injury" or "Property damage" included in the "product-completed operations" hazard. Additional insured - Vendors a. WHO IS AN INSURED under Section C. is amended to include as an additiona.i insured the person(s) or organ ization(si (referred to below as vendor) shown in the Declarations as an Additional Insured - Vendor, but only with respect to "bodily injury" or "property damage" arising out of .. Your products' which are distributed or sold in the ;,eqular course of the vendor's business and Only if this Coverage Part provides coverage tor "bodily injury" or " property damage" included within the " products- completed operations hazard". lb. The insurance afforded to the vendor is subject 'M the following additional exclusions; (1) This insurance does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (b) Any express warranty unauthorized by You; (c) Any physical or chemical change in the product made intentionally by the vendor; (d) Repackaging, unless unpacked, SOI"'!Y for the Purpose of inspection, dernors'.ation, testing, or the substitution of parts under instruction, from the manufacturer, and the , repackaged in the original container: Form SS 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to MaKC Of normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products: M Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; (g) Products which, after distribution or sale by YOU, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (h) "Bodily injury' or -property damage" arising out of the sole negligence of the vendor for its own acts or Omissions or those of its employees or anyone else acting on its behalf, However, this exclusion does not apply to: (1) The exceptions contained in Subparagraphs (d) or (f); or 00 Suet) inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the Usual course of business, in connection with the distribution or sale of the products, (2) This insurance does not apply to any insured person or organization from whom You have acquired such Products, or any ingredient, part or container, entering into. accompanying or containing such products. Additional Insured - Controlling Interest WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations as an Additional Insured - Controlling Interest but only with respect to their liability arising out of Their financial control Of YOLI; OF b. Premises they own, maintain or control while you lease Or Occupy these promises. Page 19 of 24 BUSINESS LIABILITY COVERAGE FORM This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization, 9. Additional Insured — Owners, Lessees Or Contractors — Scheduled Person Or Organization a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations as an Additional Insured -- Owner, Lessees Or Contractors. but only with respect to liability for "bodily injury.,. "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or ornissicris or the acts or ornissions of those acting on your behalf: (1) In =he performance of your ongoing operations for the additional insureds }; or (2) In connection with "your work" performed for that additional insured and included within the "products- completed operations hazard", but only if this Coverage Part provides coverage for "bodily injury" or ° property damage" included within the "prod tJ(,tS-(, OrrIp leted operations hazard". b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury", "property damage" ur "personal an advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, incIu-_F1g,_ (1) The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, designs or drawings and specifications: or (2) Supervisory, inspection, architectural or engineering activities. 10. Additional Insured — Co-Owner Of Insured Premises WHO IS AN INSURED Linder Section C. is amended to include as an additional insured the person(s) or Organization(s) shown in the Declarations as an Additional Insured -- Co- Owner Of Insured Premises, but only with respect to their liability as co-owner of the premises shown in the Declarations. Page 20 of 24 The limits of insurance that apply to additional insureds are described in Section D. — Limits Of Insurance, Now this insurance applies when other insurance is available to an additional insured is described in the Other Insurance Condition in Section E. — Liability And Medical Expenses General Conditions. G. LIABILITY AND MEDICAL EXPENSES DEFINITIONS I. "Advertisement" means the widespread public dissemination of information or images that has the purpose of inducing the sale of goods, products or services through: a. (1) Radio; (2) Television; (3) Billboard; (4) Magazine: (5) Newspaper; b. The Internet, but only that part of a web site that is about goods, products or services for the purposes of inducing the sale of goods, products or services: or C. Any other publication that is given widespread public distribution. However, "advertisement" does not include: a. The design, printed material, information or images contained in, on or upon the packaging or labeling Of any goods or products; or b. An interactive conversation between or among persons through a computer network. 2, "Advertising idea" means any idea for an advertisement", 3. "Asbestos hazard" means an exposure or threat of exposure to the actual or alleged properties of asbestos and includes the mere presence of asbestos in any form. 4. "Auto" means a land 111010f vehicle, trailer or serni-trailer designed for travel on public roads, including any attached machinery or equipment. But "auto" does not include "Irnobile equipment", 5. 'Bodily injury" means physical: a. Injury: b. Sickness; or C. Disease Sustained by a person and, if arising out of the above, mental anguish or death at any time, 6, "Coverage territory" rneans: Form SS 00 08 04 05 CERTHOLDER COPY NF STATE COMPENSATION INSURANCE FUND P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE • ISSUE DATE: 07 -08 -2009 r THE CITY OF SANTA ANA NF 1439 S BROADWAY SANTA ANA CA 92707 -1712 GROUP: POLICY NUMBER: 1933299 -2009 CERTIFICATE ID: 108 CERTIFICATE EXPIRES: 07 -01 -2010 07 -01- 2009/07 -01 -2010 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 52 DATED 07 -07 -2009 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 policy 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 to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. tTHORI�ZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07 -01 -2009 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER WITTMAN ENTERPRISES LLC 21 BLUE SKY COURT SUITE A SACRAMENTO CA 95828 WROVED AS TO FORM �-,iitt Sheedy Assiswia City Attorney E 'z' d ! �fi 6QDt NF VNV Ivi %t. [VMR,NF] (REV.2 -05) PRINTED : 07 -08 -2009 WITTENT -01 A'c`'°''� °� CERTIFICATE OF LIABILITY INSURANCE DATE% S�ZO;;1ry' 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 eertlflcate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condltlons of the policy, cartaln pollcles may raqulra an endorsement. A statement on this cartiflcata does not confer rights to the certificate holder In Ilau of such andorsement(s). PRODUCER Wells Fargo Insurance $eNICBS USA, InG. NAMEACT Tracy Dolan PHONE g'I6 23'1 -'1757 aG No , 9'16 231 -'1868 CA DOI Lic. #OD08408 (916) 231 -1741 1'10'17 Cobblerock Drives, Suites 1l)lJ E -MAIL [rac Bolan wellsfar o.com ADDRESS: y� @ 9 Rancho Cordova, CA 95670 -6049 INSURERS AFFORDING COVERAGE NAIC A Hartford Casual Insurance Com an INSURER A : � p y 29424 INSURED Wittman Enterprises, LLC INSURER B : National FIrO Insure nca Company of Hartford 20478 INSURER c : Evanston Insurance Company 35378 PO Box 269'1'10 INSURER D INSURER E Sacramento, CA 95826 INSURER F COVERAGES CERTIFICATE NUMBER• 2875443 REVISION NUMBER• Sea hBlDw 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 LTR TYPE OF INSURANCE ADOL SUER POLICY NUMBER MM /DD /VVYY MM /DD�YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY 57S BAAT6490 07/0'1/20'1 i 07/0'1/20'12 EACH OCCU RRENGE $ 2.000.000 DAMA NTED PREMISES Ea occu rrenca $ 300,000 MED EXP Any one parson) $ 10,000 CLAIMS -MADE � OCCUR PERSONAL 8 ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4,000,000 X POLICY PRO LOC $ B AUTOMOBILE LIA9ILITY 840'12487490 07 /oi /201 "1 07/O'I/20�2 COMBINED SINGLE LIMIT (Ea accitlanU 1,000,000 X _ BODILY INJURY (Par person) $ ANY AUTO ALL.OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accitlant $ A X UMBRELLA LIAB X ,JCCUR 57S BAAT6490 07 /O� /20'1 'I 07/0'1/20'12 EACH OCCURRENCE $ 2.000,000 AGGREGATE $ 2,000,000 EXCESS LIAB CLAIMS -MADE OFD X RETENTION 10,000 $ WORKERS COMPENSATION AS WC 9TATD- OTH- AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNE WEXEGUTIVE OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) N / A �— /�� "'� E.L. DISEASE - EA EMPLOYE $ If yes, tlaseriba under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C Prof Liability E084 M� /0'1/20'12 $1,000.000/$2,000,000 C� DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder named additional insured par attached form SS0008 04/05, pages 18 -20. x'10 day notice applies if cancelled for non - payment of premium. CERTIFICATE HOLDER CANCELLATION The ACORD name and logo are reglatarad marks of AcoRD ©'1988 -20'1 O ACORD CORPORATION. All rights reserved. ACORD 25 (20'10/05) 1 1111111 III 1111111 I'll IIII 111111 IIII VIII VIII VIII VIII IIII VIII VIII VIII VIII IIII I'II 'CYBOtAl S000]3B/0205 /WO /O /O' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. '1439 Broadway Santa Ana, CA 9270'1 AUTHORIZED REPRESENTATIVE 9�-- -- The ACORD name and logo are reglatarad marks of AcoRD ©'1988 -20'1 O ACORD CORPORATION. All rights reserved. ACORD 25 (20'10/05) 1 1111111 III 1111111 I'll IIII 111111 IIII VIII VIII VIII VIII IIII VIII VIII VIII VIII IIII I'II 'CYBOtAl S000]3B/0205 /WO /O /O' BUSINESS LIA$ILITI' �C?ilEi"LAG;= 1 =ORRlI �. C?PTIIUIN�►L �i,!'?[.71Tr�C.lNA1.. #niisu�z�a [�v��z.,ia,�s ii list�tl or _rlhravtrn as ��ptisa<toiea in tfars C�tarlar;�tiaras, ears tar rnr:srTS caf. IPre feaiirswlrtcp C�}atierna3 A:rldikirnai irr�;axcrcl C�rrwe3r �a�c::s aaEE.sa ,:apaNly.: tx"Jhen any at` kkak35EA Capgiora�rl r"�de:9lticara::rk inae.Ared GovsraE�.es appiy� Paractral?tl' 6. {.�tdN:ifkSOnel InSUrst�s When F2:asiuruel tJy Written C:srntra�ct. iNritt�rn Rgr��c�meant rsr F'carrrait} aF S$utart AC., `J1lra ly Ar1 Insurae�, derer�; nrre aplsiy la th�r parson ar rar�ar- rizatirsn shcaavn in tlae: 1:3ae:lar.dt9ans- ThESES cpverc-as,�Es Caren sutajr�et taa Itae tE:rrns and ccanriiti�i €as r3�Nlic2ttairi.• ter �.iW Slrle3ss t_ica�liky �trvrray� Irk tkats iaaiiN;y, �axerr gat as gro�rided ksegaw_ 'l. Addktlanal least,tr�rd - De�skgnated i�tnrscan L7r i]cga n Iza ti rbn LnJI "[C� I� E'!,hl €hi5iJF21rl:> ur:dEr �e�cti+7n C. is axrir�rtci�r.� #E:a iracitarlE� a�� Kzn a[Jaiitatrnal insure the tae�rcaeai;sy crr crr�ar€i�aslcara(s) sta•nwre ira #Pa•,5* Gr:�t;lar�aticrn:;, b €,# caraly ;,vi #la rsastre;ct t�La Iar�F�llity frrr " °tassciily irajury" ' °preagcarty raarreacke "' c:r "pr3rsora�al ar•rri r €cjvESrtrsir -iq 1rrJr:ary,• catrsect, "sri wlaaaicn ear ira I:n•�rt, lay ycsur ackEn vat eanaiesran5 rsr khca acts ctir saat,issioras et tlaosc actdnc� tart yrat.er tarrtaalt. aai. Ira tkae Fa ETrfcarnadrtcEr- ut ycaur rara�caira� Copr7ratsaras; csr D, Ira corrrtectiQr -r witia yatar }aremses awned by cnr :rt�nted t€a ycats. �. ,Add "atlanr�l frastueaci - IMan;�gters Or Lessors Cif Prr�mtsa,s a. �V!,%HC:.'Y t� AN IiVSL�REt.7 urtcicr Sec;tir�rn �. 3s �unr *nsycac:i kaa irrCrl[rcle� ans an eclditkcan��l irast.rreci tI"ttr �xc�rs•rsra�`�y car orgrteal�atie3n(:�) shca+wn In the C3eclararirans a;a t�aa �d�diticrxtaF InSeurr»!~ti - 17esisn� #eci F#Ersor, C}r �ry�nnizE�tisira„ but aa-r3y with rEssrbE;ct lct iiEalaility drisrre� eaut caf ihrei [a'wvrrer;;rap, rrasnirrtE::raanc[: ar use ssf tlaa# }�xart eT tFue rsrerrrise:s ir3ssud td you grad staawra In ttae C3rclEnra"tir3ras. #�. +�v'itM, rec>prrt t[a thEa insUrEincE' affrarrlCCk tr.� threw:sa:� taaitrtieanaal ingurerls, the e>taowttac} acldit6sanal rxckusiany a1�pJy: 71as instararraaraar t�eaes ntrt a.�l:r�riy tra_ �i) .moray "eaccurrN�ract�'" wlaich tekrs;a paltaE:e ratterr ycau eerie to kae ra tt,nant in that IarEartaiaEaas ar- (2/ �....trurtear: all aiteratkcrns, nr3:v ccsraveructltzea car [3aNmagttan op,eratnns pa=.€'Ptarna�aet try rrr cra behr&eit of such p+3rs�^�ra air r:3rt�Eiriiz�atisare. Pag>r k83 crf 24 3. Addlticaraul Instxrrad - C•3rat.rator C)i 1='ranarhis�e WHCJ l5 � It;t�UREl:a trntte -r Se?i;ticlra �. is an7enried to inciude Ens ara additisrn�al irisa.rrsci the pE:r9caniej or argarai�atisan(s1 slas.'an✓rr in tta G¢3clsrrd�flc:rr• €A; a� sra Aeta7itkeanzai IrasurE::ai Granectir �:;1' 1'✓'r�nchisaa, brat rsraty� witia r•ctrlge:tJt tca tiae�ir liabil#y as clrGaa7tur raf fraract�iisc t•n ycrra, �I. Additianal Ira�urr�c3 - Les�ur Cif Lssrs�ed Equ[p€nent a. iNHCa 35 fs.FV IP,i,iJl�iC9 a.rneaer >E?cticn C:_ is arwxnrar�a_a *r1 ea�E irae:la.At7ca «ar aaa r.�tairlkgicirtal irtsuree:i Fhe {ac:r�rants,p crr Krrt�- kan'rr3 # €an�.�) shrelwra ira 1Yte3 CPeclar��tic/ras as ar7 daa:t€iiti�enal fa'asurvc€ ..... Lersscar :rk t- r.,�ayecl F_r�uiFaaaae nq. brat c3nly with r+.,Fsact to iit3Giiity Fsar "klarsily irajtrry "'. "r�rr3F��. -�ty r�arn�o�c:" r }s. "tsrr<r•��rirsal arrc3 advartisirrc,� injury'" r.;x�rsE;d, in wrtxtait3 ur in I:,ard, by yc:aur rra�niaa#t�3naer -ict a:ri_sc;:r�a..icraa or utsa Eat Gs:it.rilaraterrt. £r.:a;��r�cl t <:� ynr,A kAy ;t.as;h 1�'er sa is i :tea car crraq erq lzat ran (s p. ts.. hNith re::sF:e3ct #e� kFicr. ira:�car�ta-ir,/,r �Atftara.Je�a:i to star: °san inete:fitiutar:A[ Insured.sa, q.hia inst.ar:�rau� ds:re:s nr.rt ai'iil�ly #n any , "ercatrrrE;'racu" vvisicPa raises glace at$Nrr y'oaa e;ta�ASEr qea It.a:se: kfN'ra# edq tsi{:rm t;aat. 5, Aeic3ittrsnal Inas�ar[ati - Crwrt�rrs: Or Clther Interests: t�rnraa Vifl�aarn L:.aind Flan �#�a+ara less ed a, 'Vi1# -iC} iS Altl 11V.''-al.JFiELI tt.n[iE'r SflG:tian C. is amc3na.iE�{i tea Incluci�En was an �.trir�it3urria.i irasursd tiara ;rEtr:7t3ra(;gj ur crrp��:rraiar�aticstal;s'} siawn ia� tl'ae QE3ciar;�tiorrs as Diet ,�+.ctdi #issra�n! iresurrns9 -- €7i ^�rrcjrs C'�)r [:?kl'avur Irrteresas Fuca:.. u'!Jxrc+raw t..i�ns� Ha�tt3 l:�c:+ea-i t..e.,;asMd, L /a.at EA rriy arvitta resgau =e. -l: t€s Iicttrility rsrisirr,y crut r'sf elate rswnershi�,. aa3�airrtenvnc;e tar usr� ra+f tlasq part rrf ktaEa [E�nr� ieernsE:ri to yc+u r.rar] ara•r,ewn 'sn the:. T� eclar:�ti carass.. b. L^With rt:spcct to ttae insurance c�€ftrarr:9tfct kr_s t1�eQSe aclt�ItianEal insur�.ds, tk-ar� tollcs��inr� 3cts�itir,]nal E3x�tu ^aipt?S aHrpiy_ `rtais ir'tsurarace: c9aae� Hart :.r proply 4:r�: {7) 6hny "ca�atarr�a'rc:e °' eh�st takes talaic:€ afirr ysau cc3ase kta 1.c:es�En tYa�at i.�art.��_ ear (2) �trtrr:ttaral alt€;ratanras, na:�� ceaaastructko�n ur eieancariti[,rt t;;aFeea•intis5ras ��rsrfcarraae';d ❑y ur E�a-i kauhalq- uq suck, �retr.,€an nr earr;par.i1- atica:a. 6. eildditional tra�Etr+3d - ..'Stage C?r Pcalitiea! 5ubclkwkslora — P'erra°aits &. rJ'rlI'ICJ iS AN I1VStJi°ti_C� rrne:ic:r �c.GttC3n �- is E:earaenracEasci ta:r tiac:YeaGe x�ET an aCidrtir�nEat irasureei ttarn stag- +_yr laol'tticrsq r;Lakaciivisics =� sfrcawra in the: t.�eck;:araitrans a:3 tin ,sieditiriraE�t Ftarrn S5 44 48 t)4 45 I IIIIIII III IIIIIII IIII VIII IIIIII IIII IIII IIII VIII VIII VIII VIII VIII VIII VIII IIII IIII -CY90 tA15/000:i39/03 /USO /U /D /U- ErtsureE3 . -..- �t�as:cr %'3a F'uiiticai Sutarii�visir✓n .. �c:rntits, trait cyrely ;vittt res}ar.�ct to ceperati�rrns xaE�i•iEarrtraEf lay yrau ear cart yueir treuYl�ulg €car wattlnfl tfle. state car p.italitirwi sa.rtaclivisi+,rrr htas issued a �sarm.it- b. WEtty react to ttse insurance a�tTcardryr! to tfrcrscs �rE:SE�itartug ir-rsa.ircrl:s, this faElawing ��ri:ddrtiEartal exeiusEesns al:rply; "1'itis irrsurdertr✓ea ctctEes retst iappty tra: (7y ^`Etact�i',y injury ", ' °property darrra�gE; "' car "�yEarso:aaN and advertising in}ury" arisir�� caul ref ctpcnr�ticxrts prsrtvrrraec: fiai° thn state nr municipality: or {zj "E#sicJdiy irijuly" ar "proRerty ii.amagex" irtaltecir3sl in ti'E3 °`proa-tuut- caneplete€1 aperatiEaear" haa.. �r[1. I. Additional tresurod — irrsnctlors a. 1f'u'l -t Ca is ,aRFd EltiE.53Ul�Nm[:1 r,irtcl,:zr S�cliora �C, is ramencieEi tca include rss err adr.3etiranal itSea rE; Li t`t Er p�rSa�n (sj [ar ©ri„j.7rtizc'"etlGn�Sj (rctrirre:d So taelcavat as vendor) slarawn in tt'tEr C1ur:t<ar�rticarts z�;~ rsit AcidttiEana! Irtsures `✓E =.:�Ltc�r, (taut Eanty vvlth r�xspt3rt tE:r '•Fs�crd " €7y injury'" par °preiperiy darr>�ac,�e "' arising •out Qg "your pnaE3Lerts" vJhiCFa are dlstrbu�ta_td cr .sold in tYea re,.tutar course at thtr verncior'i tausirac:ss zarrE� rsrtly if thi±� C;csvuraeger Ras't prravidre5 c;ovr:erarlu for "iaeaclity njeiry" rsr "propetrty dal-rt;tvaart" included within tite3 "pr-ocMa.actya...t . tarriK:aactare4 operatitins t•tar_rarc! ". V. ' "rt're in;;tirGrr'iE�r e!'rbreiEd to the verrcicar i4 sLak>jcact to this fallowing acklitional E�xctusions_ (1 j This ir'a ur:�rtci� efoe�as peat apply tea:. (aj °'13cr}iiy trijury" #;sr "gsrttpa:rtjf daat-EagE3" €csr whicf-r tyre vendor is ct€aliyutE"d trs isa�y datttrsgfls t'-'Y rr�ason of tflP :•�ssuntption Eaf labiit #y In a contract or agreement. "phis exclusion does neat apply to lakaillty itar damac,�es tftat tt�E3 varnelcr €• wa7ati;� have: ire ti-ae :atasencc r3P tltc� reAntract or a±�retmrner�t, (by Aray Express warranty: iArteerrtitrai i�E>et by you; [c) .a'4n}i' paysiaaE or cE7emicai charrgE; in tflEy prcaciuct naacte ii�terrtaortalty t�:/ th,P venryar; ��, f�c.p:ai:kac�irsq. unless unN.aack�tc3 scal�Ey fret tit:e� pairposca of insgaectiort, dsnagnstratiOn, ter>Ung., tsr Yfi E3 sudsl'rtutiort rsf prASrta urtdf3r insai'ucticar:�r li�•raart ttt<t rrtanufaE�ec €t:r, arac9 the °ra r�rpackaged ir7 the prigin;�I cnntai nc:. r; Forme SS 4d U8 Ci4 415 Bll5lhtES9 LIA�lt4,ETY GCiVEt:tst.GlE N °[�FZM [cj .arty ftaiEt,ree ta.� make saaete inspections, r.�d�ustrxtr_oats,. t�ESSis crr senrEring sa thEw v[;ncJryr teas ac�ra�.t to ra�ak�: rtr rrtTn�aEEy r.indESrtr�k?s tra make in the usual rxaursr :tt tia.151rtL35Ey, ir3 CC9T1r7�:^- crteE:,rt th'itt'r tttE' disiriial_rtian ar sale rst -that prociuc:is; (P} L"}t�ntrsitstraticrn, irtEStJiE�rtion, serviE:ir�r} cn• reNaair caN.'sr rat €E>ns, s3xt-a:N:rt i7uctt ugter:�atior?s grerfrarrttec# et ttre veradar's premisE;s in E:cannecticAn with tt-rEA sa�Ne r>f tta�x �+rcyd ueat; (yj Prradu€:ts whicha„ aft�Ear distriEautiui7 Ear sair� tty yiiu„ Itit,v✓Et lacr.�rirt ta�r!Ied ear rE.t�3taekFr::�ct ear arstl;et .ts a cr,�nt;�inckr, part cep iri�r�acS'aE7rat Eaf cloy cttFt€ar #nirtcF or sutastarrcEe lay Ear fcaa° ihc� +�anciaa; crr �nj "Bed'iiy irtjur•y "' car "lrrsFa�trty rir�rttagar" arhsin� drat ref then a;rait nexglir,}. c�rrae cat tPer3 uESracior irar Etu yawn cats car Earnl.,slna"is or tttcA;3E� caf ifs ttrrrl:�loY�eS or hrayiynEE PN�C: a:.tint7 Ean 'ttEa behalf.. htcrwvEyvPr, iftlES axcitistean ti�Aes nest ap�riy ro_ [ay l�flEr Exr,.eNatr�brts �.;crr�t,t +ricrs.9 rrt SEabgattrar�ra[afts {d} tyr 1fj; par R;ilj :3ueh inspcataticaa'ts, �iellu;�tr'rirarotrr to :stti a�rr sc:rvirair•r €:� ,.aa the venrtor' it;.��� ti�g €a1ed in neat <c car ncarrr?::r98y urecic�r#:riceu tca makc: in the uaaiar cvvrse: of f7E.asiness, in clannrw•ctiLan xritt -1 ttae d =stritiution ar saYSA of the p rr�daacts _ �2j "1 "his insaarancEj dc;aes rrEat apply to ;ire *,r ir-lsured raE3reoe� car r.rgani�E3tican frran� wt�cnt ptsv bawl, prNUireet stAr.ta products, rrr c'iny' Inr�re:dient, {sett par crsrtt�tintar, c:ritc:rireta ir�tca_ :acwcampi�nyia�r� ear i-.a�rtfi:�irair�a,� �urh prrr9ucls. 8. Addltlonal tnsurod — Controllinr� trttor ®st 'WHEN I� A.€+I IN�sU��13 urrrls�r '..SEnc'.tir�n C. i:Y arntar'rd+:3d tC) irai:lUr:i4 r "x5S Er r1 rcaCldrA4ane1 artsc.arE::r:9 the pE;r- s•an(s� ear arganSzeatian4.$) sttiowarn in €he i.3E:clarations as �3n I•?.rxctitar7a,1 Irastart.;� ...- C�'caratri�CEn�E lrtt+�rEast, tsEit Early rewitla re.:�clara.t #<, their- lialaiEity arisin€� trEitca,t- a. Their fkaaracir�l ccarttreE rat yrau; raa- 6.. F'r!en�iac:s tltsayr o,.vn,. rrtetint�.rirr or E:cantral WliiEr yCati iFi"tSL' car EaGi.:l.i F;i.ir tl7 E'tiE:3 �7t't; l'YIISE':r. Pralge 15 of 2� I IIIIIII III IIIIIII IIII VIII IIIIII IIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII �,." ",e,v,,,, ",. ",,,a, "s, ",,,,,,,,, �uslr+less r_ {aeIL1T1P ect�rl"t =a�r�� �ot�enn This insurance does a5gt ap{aly Co s -l�ruc #oral s91tG= rr�t1r?ra S, rai?w F:�:rriatril CtlUn :drlrf ClrOrrr2stitira rY tapr�r�t:ttcaras prarCcarreac:d lay car fvr that prarsnra ear tarc�an iz�a ti nr a. Ll. Adefrtdpna# insured — �wnars, Lass+b�ffi C)r Ct9r�trantrars _. Sci'redulFrd firersnn Qr- {]r81en t.x at #ore a. Ft {!9, 1�3 .tii'J IN�iJi�E:�C] ur7r�er 5er:;tcrrr G. is anar�•at�n�rr^.,:C to inc: {udF: as an additranal frr:suric{ the A €:rscznCsi or orr�aanizatgre(s) shown In Cka� Car=s.laratigns a•s an .Additional Insiar�crd -- C}awrirxr, Lraa�r>cEas C]r 'Cyontr':�Ctnra: brat taraly oSalErr ras {:ie9r:lt tr:k 1 {c�lallity for' "brsclily ir'e�ury'" " "�froperrty durndg:cn" ar "pear soar €r�l a�r�lcl acivea #isin�r irrjrary„ t:r� used, to wFeole c7r irr part. try ;�vF.�r sE is nr ciraiis�ivns or ttF�: air:ts car rarnissic:ra� csf th vsr: acting ran y:acar be:h �eJf: t�) Ire Clara {sea rfsarxrxa�nsaea r:rt yo�rr• taragtuinr� o {:ae=,rratigaas fray fhe r�ddititalaaii irasurraceja }; tar (2) in gcit�ra�ctiora w.it #a "ycaur wvgric" perFcarmPd for That additional insurr�d ell r' €[: in &�16.arl r:d. wit {•ei€•^I 'Cf1 '�: "'{:lrra[liJCtii- r:caraa{aketraaY oparaiigns hazard ", but [artily it t#ais Ggvorcayce iP�rt prow {[teats .ctaur�r'caf#e!* for "t =sacli{y injury" era• "'�arta`aaarty f9arraa�e" Incluclea� within tfre "pr-nr-tuct5- campleated o�eration4 rr�rzcirri "- b. 'V!Jith aespact to zhe Inswrance :afFordawti t€� thr;+G� addiiinn ai insura3 sis, this insurane:t titxa ratat rr{a�a =ry lets "beadily ir€jury ", "prvpvrty tiarrarar�c "• ear. "iae5rsesra=al arts acfvtartisinca ira,jury" o�ri >air'rg tr€at of thre rtanrjerirag rzl', car treats fJilrrry tta riaraCik2a, gray {arofta;;siora<ak arcltitE3rturrts, a3 rrs�ir?a:Erincy rar :surveyarac{ �:arrdictas, itacta.at:{ins;;: qi) T #au;: {•�,rur:ar;rriir'rc, }, r�{e {ariavtrrR,y, ear f�aa #aarc tv prc:�arrrea car approvs: mrr;fas, si• €op dr:trwra�5, ea{.:inirar7s.- r�_ports, surerrays, I�atatr.# cerei�a�s, cheant�-u c�rd�rs, dr�sicJns ear' dr�xvrrirrc7s a�n;i specifaeatia�ns; rar (2) Sup�ervir;ury, irastacet:ticara„ srcaitr�ctural rar° e:n °I; # €r•lesariaac.# �r:tivti ©s. •t i3. Acldutioraaeti lrasulra!+CY -• a�a- Civrrn ®r C?f Iraa�uragd yrQA'A'7i8QS w }tCr BS a4.N 1Nr�lJF%Ei3 under S�ctaan C- is ;arrac:rada�ad �tca rar::lr�dv,�= gas arts Kseldilinncal insured the persryrw�sY car �7rgaraizatir�ra(s;) sh�nwn In the L7ucl2eratiearts as an A+�ditirrrral fnsureed . -. s:.€:a- L7wn�ur C7f lnsuret7 1= 'rorrrises, brat ortlyr rvithr r•aMs�ncut t.rs tka.�ir liat�ilkty as ccs -awner of the {sr+�rraistiis .s #tcs+rrrh in f #-re t�s3+aiarations. Pa�lg 2r]' af' 24 000000 Then 1 {€•nits ruf iresursar €cam that � {a�'afy to acic3itira €•r�aC e•e�urc:+.ris �:Irt;a uusr~ribud ia•a :sr;utnra L'3. ... { „irraits �]f Insuranr;ra. i-Icsw this insurance r��apliies whrwrl gthw~r inaurpnnn [s availatA{[r tq an ®dditaon;�€ ire;5urrsd is dr.�scrii'Lrer� in tfen C3ther Insurs,nce C:raa•edfinr•a rro �oL:tgrr E -. -- Laabitity And 14tr3dic.�t Cxtana�sess G�n€�r�rt Cearlditieans- LiAE311..ITY Ai�IC]i iiEl�[3fC.+I -�L. li*JCF�EI�i�E� iDEFIh11T1€31V � 1. "r'Ac�vr�rii„sement” rret:rans RYte vrridt'.s$a rc •.�c# #��sk,l €s:� rtiSSr:n�inatiEyn rsf infprm;�tir�n qr in�a•{�� -s Chat 'tans the purpose of Iradr- €r;ing tfe�e �.�aio of ti�eagds,. prractucts tar snr•�ices thrcru:�{ta. a. I['t � t�l�t:3ir�; {E} "'r'sit3visican; (3) E3iiity[aarri, (�,� Mfls3 �{2a..� ".Imes. {5} PVf�rrs�aapar; b. TYrB Internet, bCit gr�rly Cleat pari: of a rah sitEr that is about g3gvcJs, prgduet& yr Sr:rvices fne- ilea purposc.�s of induSirag thn 5sl:e of goodsa prr� ducts or sr rvic ::s car c. Aray ottarzr Eaublia..aticrr7 tYaat is gi�drsra widaMs�rreac9 {�r.ata {lets cttseritar.rtit:arn.. 1 °#ow[rs ✓er, "adv+ariis:enient" tfc•�e� -�� real inrlra.:9�- a. Trr� drasigra, printESt9 rrae�:rir`al. infr�+rl- raatiLra car lrero�a�t:^� c;aaceatrair €ral�l ire, Lira rar ragatara ih'ra: +. pa•cksgin� qr {�ka�alinct a�,f any �rrc:cecic: car farryducts, cx b. Fhra int>:±rae6i•�r€a coaa� ✓er�;atiun Yse:twaarl err ��rnaccenc{ {3e?r'�:carastkra• €araA #:Y•I �a tar•rrrl {x•rzia�r ne�evaUr{e. 2. "'iadwr:etisinc#: idea" means a€ny ic{fa fear an "adv� rti s aarrae nt ".. 3. ' "ar5sbt�stt.rx': h�za�rrd" ceaae:eara�: car's e3:n {:e�rsur€e <sr• t#arc:�t caf ex}aca�utare to the r:€c8rr:rl rar- aallea:�L €� {srupr,:r•Rics caf astaestasF c:rn :.I irar:ir.ac9cxs ttt€:a rraaare, �areseynce a�f asbestras in rxrry ft�rrtt.. 4. ' "flutes•• rrre�ens :� {:and rrrca tzar' ,�:c:kerr::ies, tr'e1.71c±r• nr serrai...ira�iior d{tsigaaed nr trx-ew�ra! ura {sukrlir: rvaeis, incdudinq arrY at2a�c;t'I[:ct m,sr�#ninr.rx err s3quiprnE.nt_ but "awty "' do•vs not inclfrdq °raatatai'dr:s e:r{ui{arrrerat ".. S. " °Bodily Injury" naaans {rkay51ca7sl: a. Infury. c. C3dseasr~ s�ust2airatrd Lay ca {aersun :3rad, if darisrral'f writ s:Ff tlac.� akstave: nav = =nf.al a�ny�€isir or rJe:.•a #ta :�t n3rry tirn�. fi. "Coverage terriEgs�+" r'raeans= Fr3r'n -r SS UO k?f# t)4 fl5 I IIIIIII III IIIIIII IIII VIII IIIIII IIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII -rvran.nis.nnnr.w.nsms.n.mn,n� �`1 Ll� i %,17D"l '-' ��.� / WITTENT -01 AGIMROTH .�coRO� CERTIFICATE OF LIABILITY INSURANCE �� DATE (MM /DD/YYYY) 6/29/20�'I _ _ 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 CE�iTdFI�A�TE ODD _ IMPORTANT: If the certificate holder is an ADDITIONAL INSU RED; tl�e i7ty(ies) must 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 endorsements .` - � - � PRODUCER LICen Se i/ OG9848O ". �� �� � NTACT NAME - Western Elite Insurance Solutions ' � ' ' PO BOX 2980 Rocklin, CA 95677 '-PH°I'IE 9'16 259 -6900 FP'X (866) 206 -8646 A/C No Ezt : ( ) A/C No E -MAIL ADDRESS: INSURER S) AFFORDING COVERAGE NAIC p INSURER A: RQpUbIiC Indemnity Compan INSURED INSURER B - _ INSURER C Wittman Enterprises LLC INSURER D PO BOX 269'1'1 O Sacramento, CA 95826 INSURER E INSURER F COVERAGES CERTIFICATE NUP- .^.BER: 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 LTR TYPE OF INSURANCE POLICY NUMBER MM DD/YYYY MM /DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ PREMISES Ea occurrence $ COMMERCU\L GENERAL LIABILITY CLAIMS�NADE � OCCUR MED EXP (Any one person) S PERSONAL B. ADV INJURY $ GENERAL AGGREGATE $ w� APPR AS M GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY J COMBINED SINGLE LIMIT Ea accitlant BODILY INJVRY (Par parson) $ ANY AUTO / AUTOS NED AUTOSULED AITB A M. C �� BODILY INJURY (Per accitlen[) $ FeOscud DAMAGE $ HIRED AUTOS AN�NO NRJED Te....t�. City Attorse a�^�ii�^�'' $ UMBRELLA DAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS DAB CLAIMS�AADE DED RETENTION $ $ A AND EMPLOYERSE DABIDTY ANY PROPRIETOR/PARTNER/EXECUTIVE Y(� 'L 8'1894 -Oi 7 /'I /2U'I� 7 /'I /2U'I2 X V�/C STATU- OTH- E. L. EACH ACCIDENT $ �I,000sOOO OFFICER/MEMBER EXCLUDED4 I J (Mantlatcry in NH) N/A - E.L. DISEASE - EA EMPLOYEE $ f ,000,000 I( yes, describe untler DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 tv �� O _� DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Atltlklonal Rsmarb Schedule, H more specs Ie requlrad) L_ TI Q C r— � � I m c/-, c.J'I o b rT, z �_ D W Y z CERTIFICATE HOLDER CANCELLATION W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. '1439 S. Braodway Santa Ana, CA 92707 AUTHORIZED REPRESENTATIVE I ©'1988 -20'10 ACORD CORPORATION. All rights reserved. ACORD 25 (20'10/05) The ACORD name and logo are registered marks of ACORD IN REPLY REFER TO: JULY 7, 2011 THE C I TY OF SANTA ANA 1439 S BROADWAY SANTA ANA CA 92707 -1712 CERTIFICATE OF WORKERS' ----------------------- COMPENSAT I ON I N SURANCE ---------------- - - - - -- LANCE LLAT I ON NOTICE ------------- - - - - -- RE. CERTIFICATE DATED JULY 1, 2010 THE WORKERS ' COMPENSATION I N SURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JULY 1, 2011 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAME D B E LOW EMPLOYER: W I TTMAN ENTERPRISE S LLC PO BOX 269110 SACRAMENTO, CA 95826 POLICY 1933299 -10 CUSTOMER SERVICES UNIT SACRAMENTO DISTRICT OFFICE (916) 924 -5072 5860 Owens Drive - Pleasanton, GA 94588 -3900 Mailing Address: P.O. Box 81 92 - Pleasanton, CA 94588 -9682 SCIF 19102 JULY 7, 2011 THE C I TY OF SANTA ANA 1439 S BROADWAY SANTA ANA CA 92707 -1712 CITY OF SANTA ANA FIRE DEPT. 2011 JUL I I P I= 4 4 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------- - - - - -- LANCE L LAT I ON NOTICE ------------- - - - - -- RE: CERTIFICATE DATED JULY 1, 2011 IN REPLY REFER TO: THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JULY 1, 2011 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTAC T THE EMPLOYE R NAMED BELOW EMPLOYER: WITTMAN ENTERPRISES LLC PO BOX 269110 SACRAMENTO, CA 95826 POLICY 1933299 -11 CUSTOMER S ERV I CE S UN I T SACRAMENTO DISTRICT OFFICE (916) 924 -5072 5860 Owens Drive - Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 - Pleasanton, CA 94588 -9682 SCIF t9 t02 WITTENT -Ol - `'�'��O® G'ERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYW) 6/1 5/20'1 1 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 pollcy(les) must 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 Ileu of such andorsement(s). PRODUCER Walls Fargo Insurance Services USA, Inc. NAMEACT Tracy Dolan PHONE g16 231 -1757 ac No : 916 231 -1868 CA DOI Lic. #OD08408 (9'16) 23'1- '174'1 11077 Cobblarock Drive, Suite lOO E -MAIL trac Bolan wallsfar o.com ADDRESS: Y� @ 9 Rancho Cordova, CA 95670 -6049 INSURERS AFFORDING COVERAGE NAIG N Hartford Casual Insurance Com an INSURER A : tY P Y 29424 INSURED Wittman Enterprises, LLC INSURER B : National Fire Insurance Company of Hartford 20478 INSURER c : Evanston Insurance Company 35375 PO Box 269110 INSURER D INSURER E Sacramento, CA 95826 INSURER F COVERAGES CERTIFICATE NUMBER: 1875443 REVISION NUMBER- moo r,olr.... 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM /DD /VYYY POLICY EXP MM /DD /YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY 575 BAAT6490 07/01 /2011 07/01/2012 EACH OCCURRENCE $ 2,000,000 DAMA E E ED PREMISES Ea occurrence $ 300,000 MED EXP Any one parson) $ X0,000 CLAIMS -MADE � OCCUR PERSONAL B ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4,000,000 X POLICY PRO LOC $ B AUTOMOBILE LIABILITY 84012487490 07/01/2011 07/01/2012 COMBINED SINGLE LIMIT LEa accident) 1,DOq wo X _ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per acdtlent) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Par accitlanl $ $ A X UMBRELLA LIAB X OCCUR 57S BAAT6490 07/01/2011 07/01/2012 EACH OCCURRENCE $ z,000.000 AGGREGATE $ 2,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION 10 000 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXEC UTIVE OFFICER/MEMBER EXCLUDED? � (Mantlatory In NH) N / A �— ''� E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below � E.L. DISEASE - POLICY LIMIT $ C Prof Liability E084 M� /01/2012 $f ,000.000/$z,000,000 �y �+�r DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Atlditional Ramarka Schedule, If more apace fs required) Certificate holder named additional insured par attached form SS0008 04/05, pages 18 -20. `10 day notice applies if cancelled for non - payment of premium. IiCK l lrlliA l C r10LIJCK GANG CLLAT ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1439 BfoadWay ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE fj Yew._ The ACORD Hama and loco era raaistarad marks of ACORD CJ 1988- 20'IOJACORD CORPORATION_ All rinhfa rwxnrvwd_ ACORD 25 (2010/05) I IIIIIII III IIIIIII IIII VIII 111111 IIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII •cveotAi v0003aa�ovos/wo/o /o• BUSINESS L1I4$ILIT't' �C?idE#2AGE �C)1�19l1 �. C3Pl`IK31VAtL AE?CJITfCiNAI.. INSLJFYE[� 3. 6lddttiansel Insurmd - C3raswYtear C7f t= ranchese GC)VER.J•►,tC"sE•5 WI--IC] IS Fk tts3�i)Y�EEJ� i3nx�er StsC;tior5 C. is 7F tinted r7r s9- IC7vstn as raC:3�Alinabtn in tPtF9 Cita6.laralians, an ?enriJ�d ica {nclude as ran ad��tic>n�al insRla c5ci nne. ctr rrtrrtr c5'P the: tealir-wirtcl C.)prlrrnal JMLtditianat file p�rsc-nn[s) or nrgani;zaation(sj shr'rwr'I in Ih'~a ir'eseirf:R:9 C:.crvnra{�c �: salse:J Japply. Vh/hen an�1 of tFdase t�cclara'tiur'€s �;; .::err AetR9rtiRan�'J Inti:J:JrR::ti - C)pticse-lat btr3R31trrsA3::it InscarFSCi Gcverayes apply, Grantor Vii' I'�rar5chissa. twat rarely 3N'rtll Arj:ai7ect tca �'i3rac�rap7151 Fe. �r�6'idttiR3nal InStkrc:d5 WWheYn Rr:qurt3d lhctr li�lbilily as yr�it�ltc'sr csf fir2nre-lisr 1:•67 yrr6�. t,3y rtttran i:crntr.�ct., ViFrittaan Rgr+�rym¢nnt rsr F'Rarm €t} +7- A[fditeunal Insured - i..essow C?li LR;rJasreel of Sa;�:tian aC.. `d'dhv is +qrt IrYSUrL'4t, dR]@r ,� nut apply Equipment tC3 the' pers�o €r ar' R.7Fgal-tization sPtrairvn in t15.€: a. yl`6rt -{p 15 AN tN�Ui•2iwta trncler ��r;.clec�n C_ is C3a6:a€ra7taca€�5. Thaw Cc3vara9E?>s r3rc3 suttjcr;2 tR:t ti5a �er34�nflRart to il'tc.la.ac�E3 as a. €� w�aJtliii6:artai terms and nr3nc9itioe'tJ� s►isplic�it'a3x�� Fn"s t3usine3�;s irtsure!.'1 tPre3 f.aer. cart {s,p nr c�FgF-tni:.aieon:�j i_iaYdalFty i:vverdye In tktis }�oliR;y, Aaxcat7t as shFnwrS ir? ttta3 CPectaratlRrns as clr5 lAd:iltl._ana3 �dre�vided :kse9R]w:. IrSSU:red ..... tE3ssc+A- ❑t t_C:aaeci F�uiPi ?5t ni. 1_ Addtaraner Inse.lred - N]naignated PerA>,an Car F.ut c3nly with re;,pR+:t tc ii6at3iiityr for "hardly C,1�Fg.'anlzaticsn irgjury °'. "props: -rt+,r r,etrYt��'.[_ "' rs€• "'p�rti.= �5r'a�al 9JU1 -t C) IS r�P +t 9hiS;.rt'2E[3 tJneter Bastian C:. §s and advertisin[7 Injury "� er>,rrse:c4, erl w.15o1*:a car 7rYle,n4ic�ai tr:a it ?6:•Jtrcte.: a5 Kart ad�iitCrnal insured in pert, by y6aur rrtatRYRanernce:, c,rts;;ratic>n ur til@ pR;�d- SCaR'1(Sj []r car�arli:�atl[3Y1(S} SI'A•C)4Nn ir5 tP'I -� Ls";L5 R_rl' R::�LFdprY1E I`It. IR.ti3'Sf;:I tR:J 'yrCal,a kr`� SC.J6:il DC3L•.i.r]ra Elfin ti. [} €at [sr51'y 1i%3tt'S r'r:SX3i:d:t iR] IA'i�t7il lt;y I;a'k'r�'SCilli..i.j [3i'rrrc7 at91zsa11ar1�:S j. far "taaLiity injury "_ "}zrcayfurty ti�air ?ac ;e "` �F �. iih rc:sFrc3ct tca €Plc; rrt:�urn €•Ir,� .wffi. =ra€^a:i trr "pe:rsr�wial �irtci �e€ivetertts'ing in,jl:rr�+'° cau�ad, ir5 thlw;.sRt acE4iitix;e ?rat ir?�.ureds, 9:his insc.ar.�:rct:. wFrrrlR:e e7r IYl I:a::e l' ?:, 1.7]1 ?f47lJr �Gt3 ar CanliS51{7ni ar G'Cae:S nsrt ii K3171�1 tC,3 any � "at:;Girrr�F.'rll�G4'" '�'+P'3Jf; P1 kit C3:�CiS C7•F 4313 ?iS'aiOnS °3r•• tt -1DSL r7{:t7C1 [,3 67 r'l yLTLFF Ik3tCC. -°5 ]7 ti9%$ E3 r'tFlf Sj Cd�i,J 6kf:: rd S4S 9.63 IBC. c7:3F3 t7 "165t 17rr1?alf� Reciuii'rrYt�:J ?t. a. Ir9 the pr3rfarmance ,7t yoR;lr or3R�aireR� 5. Additisanat Insaareci - •r�3wr3�YY� �w t7t13�xr caparatiaris; ar InterEest:a Fwam WirRarn Lamnd iaias Elet�n b. Irt cr3rtrFactior -r w3tlt your #3ren�tses c4/vned E.es3serrl by car r�+ntRyR� tEa ycita. a. 'J'V�tt3 lS Al*i 1ttil5llh�Eii? tx:n[ier �e4ti6; €1 G. is 2. Adcfetlanal Ytsuracl - tMlan;agers Or Lessors a-7rr1R3n£i6£1 tea IncluRiRa a:; ran �:Irar,Aititfrsta.l C)f Premis+aas insured tPac; pElraiTri( :,� 6:ir urR,�aee'Si:a~�eticrtis} a, W±fHCa 9� AIV IiVSL6R1v[�3 under 5ectinn �. is sl:awr. in tl'Se ®e3clerdlions as tiro ActdltJrzrS�ak lrr:�urr;ar� -, f'1Udriurs 5_ir i�lhR,.r� IrttRyre�,ia.3 F�J'6ar3 E11'1'6LnRyGtC',t �7 IrtRf "ILECJ4:: c " "3:9� an eidd111C > € }:;al 1YY56.1F$f:l ��i'IC'3rYt Lanai 1'ici!3 l�xaEtAS t R %dGtwd, t;2J,Jt nasty. iiltr �ie�_M�Car71i.�".�} isr aru�i�rtl7r'�tl [. €7r�:SJ1 SI -ICnWn ri th €3 W3tF7 rBS�5GC1_ t9 IIckP)i kittj Fr�iSlr€i� CDWt L31` t1lG t�'eG'It"'rrc'tK1 Lrn5 e3fi l�al �CI'6t1t66an$F tn$€Ylt..d - awnR�PS P1iQ" n.a in'C,ra n:,n C€3 Ur LI °u E, G'af t1'Sat. (.I Cert GBSLgrYrAt2[t I?ers4n �r f.7rtj. {.7.niZE•]tt�C3rt; Isut na'lly irr ti Ei laltf;$ lire§ tiCi4'9 to y[JW car'I C.1 sl]CYWn ll tll E:S wiktt rt.sµ�:ct sa [iatt;73ty arisir5g 6'aut c7t the: {.)f LtJA'�At:lUr'I55. c3vn/r1�,rrsPtip, r i::einte3rtartc� or use otthat art of tFSa prumis,us lr3�tsrscj try you arYC! yhawet In the b. Vh>ith respcc9 to the insur;:sncR� Kaftarr5act tra DE;cl6arcllii3ns_ tYe.rys� racldlti6snaf insureds, tyre tnlle,•�ting addiki6anal exctuaEana aFiply. b. 4Nltl� R�3s ,E =ct i6a the:. inW�'urar5ce affoldCLt tr � .� � thae:st� a3ai6fetir3ns�l insureds, t116a fic7lJastuinti I iSiW: insurarYC€i r9aa�� prat a�t r l� tc7: 1-F3 y acld:itianai excl6aslans a�iply: i('1) Any "errfcLirre�rl6,e" 'that tExkr3s plaR�R - 1'131s Ar16-ur;! +e ?,ue. R�ea��:: nRat a'ala�rly' ta: :after you r6:bH.Sa? to J:r.LLe.sis th�et li:3r'ia1; ur ("1) .arty "cdc;:urrenca" wl ?ic9-I takes placi;• {�j >truclural aikerKstaori:s, nR; *�v ��Ptttr y47u ccasra eci be a kR.:nant Mn §hat canstrur_:tinn nr demntitir3n nper;SCiarSs 13 r[3rYYi�. R35'� bar perrforrne:xi by sae' earl E:3(h2+lf u9 s6rca�3 (2,p Str3J6^tAaraal aiterakiRans, nr�.v �tetr;aFan c7r s7rr,:p;ar.11_:�taia €-�. c6rr5str-uctiarl ear ciemalFtian up+sraticrrs 6" e4dditional Insc €reri - Starke C?r Polittnal pertarn ?act by ar nn b[eh¢19t crt' such Sukldlvlstan — Permits pe:rsGrt -, ar rirc_yanizaiiort, a3. �PJI�tO iS AFd li�t�,s'Ui�l::_C.� tandee'.�',ectinn G- is Filr'1'IfeftLtRJCP t1:A iA"1 CIR.at'IE3 i�'Sr ar? 'e'3Ci Lj itianF�1 IYt54arBd ti3er Stc3 tia- itr pC3.l LtICr�9 titJ t)C:tav'i81C3�'Y Isilnwrt in IPSe iJect::rlraTtanv Karr# a:n x4cditic,nai Page 48 at 2A Form S5 DO U83 U4 ik5 oao�. I IIIIIII III IIIIIII IIII VIII IIIIII IIII Ilill IIIII'llll lull VIII VIII VIII VIII VIII IIII Illl 'CYBOlA1 P00 0 3 3 8/0 3 /OS /O /U /U /O' etusinless Li/a131LpTY CCIVEk�fi.GE FCf1"tM Ir'asLKO'fi:td ..... `utrJtkK C3K' li`'iJIEteGtil SErt7Ltl'VtlSirJre .. {�� ,qny fk3itEEre En tlll�ke s €JCh i��r'Kllit°.S, E:kElt f:)r'ely rvitll ri:S,}?ESCt t€a IKISpEGtI€an8, adjrJstrrTtzrats, tf,�Sts ar rJpura Eiryns �J�1 "tL7 rr77eCi t)y +�'DU or L)A"1 fr'i}Lf l' S6:rYFC:lncp r']S the V�FprJ[yr t'Ir'J3 arpreecr betl�elt #car �rhieh t1�G sEate ar p�rrllttir.�wt to rrl:�ke rx ncsrrrraply a.Ant#ertakes+ #ca sEElladivisiL -rrE has issued � p;sarmiE. rTi�7pLf� iri the usual exJUrse of L7. WittK rG"'S��G'.t E[e tFet3 [rJS Uf;3 nC@ EitTL)rci @Ct tCa tliJ 51x1{;5::, ir3 Ca!nrlE;.CtKL]rJ ah,'i1:t'k ih!!e #t1 €'DSFB .clE�fjlElOr7 �Ie ir75U resd S, thf3 /Qtln�/111nEj dlStrlbLKtlCln C)r S.Filt� crf th {, pf[aLtUi:fF.i :. ;r7f3dMticsri:a9 f�xc:pustf>ns af�ply: {P) p�r�mcris #x�ltifEn, i17 NitriilekilE7rt, T r'lis irE:�urdrr'rc.e� ci:•aes refit al�rpaly trJ: servicirlri far rerp)air c>p.a>;:ra #icins, {1j "'Bndjr Inyury ", "property damage "' ar oaecep)t x,fJeFl nfofaraE[icarE�; �rlWcifarrlled , ' persanai zrl€� advertisirEg in)ury at the veretlf�r' =a premises in �Erksirag faut Cif cipsrar�tians pr•�rforrne*.L: fi:)f° r�anraectinn wpth ti"ie~ Scale r.5f ttic� tf7is St�t6 cr mUrllcipatity; flr Arad UGt; {2) "L1LacJiarr in }EPry" r;r "prf�perty d.amat7er" {p�} Prf]ipUC:tS whlf:tl, 3ftrar tliStrlt'JUtIC/Jl inr:l€rfied in then "prnciurt- curllpleiefi or saicE tKy yfiu, fPevee b�.rJrl iz3k')elc:f9 npE�retica.le" haz.arcJ, car rrlr•�Laet{��a^t far' Elsf��cE �xs a conEainr.-�r, faarc ar iJ��pr�:f5ilal�t ni' r"2ll�f 7. Additional trssurrad — V�anclors othtrr ftlin[p rar sut,t„tanr�eE fa}r car far. a. WWI-C� 1S �`�tJ iiVSUI��[.a udder S•fsctinn C. is €hta +�s�rpdos'; clr errenncied tL� €rtclude f35 arl additiranfal h "Reader in u , i } Y' 1 �" car. "parup�c:rty insure=d the persons) nr L3r- ganizetitsnfsj laarll�;�€�" �Prssny croLat cif pY�ct su9r� (re.forr€s:tl fu fsealca;.�: as vertcicJr) Silpwn in trtfr neagiir,�earlce: caf tief3 ulsrticior fear it:� C]cacEtaratefsrts xis Ere Acidllifarlal 11]'� Lfrfi::Lt -• nwn aeEs nr carrris51a1 �s far thCJSe of *;r'eridckr. bcat canfy with respect tca "tandity ets eJmplayeeS r�r arlyaneJ c�psG in.lEary" r�r °prcJperty dam�Jge "' arespnE,� ceG;t. nt' acte€gc7 earl tf5 behelf. htnwv'e'4:f=r, this '•.y[7€:+r PrndKAtctS" Wtl €C!3 are drstn bated ar rexf;ItA 5[[9n dGe� not �pppy' t�C)= sntd rn ti"If-''. resgu €�Jr caursrz of tf1Ee vendor's {I� -Th!' rtixf;.ep:;tpf:Afls r.;x:rrlt;air�il�f:9 eel t:rusEK3rr`ss �8rld rJxely of this �:LaverzKy�K•* i'2re•t S €Jbfaar�Jttra�lhs {d} c)r pf }, far pr€avadlss �€avcEx -af�L ffar "tacwdity n)ury" rxr "prfapaf:arty rlcsrrir3;3t;" inclucif3d 'within Ffie3 {1E) 5ul~h Irlspeaf�tifans, .` p :yf"�crcNa.ac:ts.�earnK:eie #eid npcE�.rtfans har_cird ".: ;�e1pKa•;�tr'r•ir1K'ats, Ir�sfti a;lr sEr +viruir'lcp V- 1`F•14r' le'K;;EaraKnf:E? c�fp't€yrciad tC? thfZ Wf3nClL)r i5 a'a5 'Ehe Yell ClL7r' hi7i �'� re£d #C) sukajecttcs €h�fr�ilvwirlg adflitiPnal e�xc]usens: rraakcr far ncar r'r1a81y Ur'IdE:rrt��Ip4G; #c� mc3lf:e. in E.hfr us €lal cof,lrse rxl- (1} i' #las irlsur:ence� cpr)Ers rlfal app-rly tE7: busin€sas„ in c+aranectifaJ� ;pritfl {A} "`I�€a�tii; 1f7 §Ury" rsr "$.7rUpl:ity tiln rj.:;:trit$JJtl.Cafl nr Sf'iYe f:Jp Ef74 ij2e���k"�" fear Wt7'.rG i'E tt76 Yf3r7Ci CIK' eS prCJdkJCtS- iiEipi�F3tE:ii tr:i p;�y Clei['r"lEiPa£+S r - -]/' (�1 °f hfS InStira 11049 dLEl�S' rECAt ee p)pLjP tG 7.K1}f rt.aSiirl of #t7F i356UrM7ptinn f7T irlSUrfrd �J l3rE"ann nr CJr1,7311eTS. l3tICl17 frflJll ir5t.)Ilrt� In e"9 COJItr�Gt ar prjref�'+rrEZrlt. erlVliillT7 ya€J p,r]Wl:: 2iCf'�tJirE3E1 SLJC:ik ishir exCirJSiCJx1 tl.0(?5 neat apply to pri?dUGtS, t)Y 2%xly InC�rE'.tle[vnk, (3�rt or Ili3bllily ft;r [iame"K(,j. b8 til:r7t til@ Cl)Petcllnti r, �C:r7t4:rlKle� eeltfa_ '4'l3rECptir SMi7Eelf:p p73Llii! 1x7 fteE? tit)$e°°!'ic'c.` adGC57mpaa,Jnyi17� clr f,:CJI'7t;�,pN71k7{� b'U Gh ur thf� €�'ontract cer a�r+aolllfant: prrdLJrps. (b) J�rly express warranTy 8. Additional Insured — Controllinc,J irtkar ®st Jrl Hi LkfilK:ef I:GE'E'� t]y �QIJ; WHY^J IS }4Td IIV SUi�L -a urkd�r ':S f.'f:;,tknfl. �. i5 {G} JC:fky physical Qf Ct1BT[fs� chrans�e 2:rr1E,: rEd43rrl to lref:;iUdC3 c)iS FJn 'il Ci(i't�i�.?I'Ir "9t if15i [,eT'frCi in #he3 FJr�JCf€JCt made inlelltinrlally the parsore(sj ear c�rganiztatinrl {s} sfkrswn ixa thn b;/ the +iencycrr; C�7€actarations as zlrY }E.Lfcietiral7�al Insuref� {d� #�c�paackar�illg, unless un�aac:kecl Gcar7tr4�lRincp trrt�- "rL *st, ksc.li Welly w:it17 r�::sfaf* =,.;t tc: scstety frJr ttlQ purpxasf3 Of insfseL:pian, theel piaGliiiry arising iJEBt of: df�J7'Ir�JlStfatJafl, (i26ifn9, nr tf1E a. TtJtEEr fIK'13rkt:ir3t Ci3xl tr C'fp [)f yau; LJl" aLCbst€tutlEEr1 Cif �' rth' Ur'Ii'jf3r fJ. p�r�BrJ'11�{:.�: tt7e5r U'riir7_ rrlC3k1 ?italrl (3r C;f�rJtxUt itlTSE9ila.tlf)r3S ii'c7177 tt7l7 r71c7F7Utr"34`.tlrE97", Wu'1'7i1E' jfCIL1 lNi9S��+ pr E)GL;I.Ap:ly Efl!'.543 Fbr'4:_T1iiKe�r. 1d177d thl:`el !'t:PaCiteJgCd [17 il"if3 f)rltjire>31 cantai nf~r; Porrn SS D4 48 04 45 PEkge 19 of 24 l IIIIIIi III Illllil I'll llill lilill Illl VIII VIII VIII VIII VIII VIII VIII VIII lllll lilt I'll - cveo,wivoowieionrosioio.oro- BL3SIIV'ES5 LIABILITY GCtiIERAGE FC1F2M Ttais in:sr.erance da3as groat aptaiy t+a strue:turat aFE4S:rafi[aras, ra�a,nr r:irrrostruckican eared derrarsEifiort raparcoYtr�rts �,rrri +.srnroc�d by �r ior° fraak parsr3u'a car fare�anizsa t:Furro . 8.. AdrlJtdgnaE �Insa.lrea:d — i`jW[IegrS" Lessen$ C7r Gcrawtraetcswrt — Sci�fr�dukecl Persnn Or i3r�anixatFOra a. 1J'dl °It�) 1°a" A#rl IhI41Jf�E:�LI urroder �ec:tir-rn G. is >n€aroapndetf ft� inrka.adr a.s an adcfificsnaal kn:sure:ck ttte= pt:rsen(s} car rarganizes[Lantsj skta»,vn ir'e 8 -he Deciar9ficsn5 ass an lf+dditicanel Insure -d -- Ckvarn r3r, L�sSF.;r3s �l�r Crrontr�cears; raa.ae c,rrFq/ vaitrr rsspec.t to lt.'€bility fL-€r• "bodily irrojury° „� =tr�Vrar'ly d�merya'" or "�rsrsorsal arrotl a�clwrs: €# €slarocF iri�lar }" er�usc,d, kn uanc�rla or in �,a�rt, tay ;yrear acTts ear �ra�issirans car #Fra~ acts err ramissic:als of tiroosr� acfing care yzaLir bvh�tF: {i) Irro ,`hta peorts3rrxro::rort =.. >e et yoLrr e3rtquinr�. c�laeraticaejs fee the additicarroai le'ISLIU'ra Cf(;`..]; er [2) In conr:oceion with "your ,avtarrc" pe�rfUrnroed for that additional inSr.�rerf ear'€e� incluileey WFthln 't #te '•FsrC7dieCt:�- rararnptatad Ca�ieraticans ha- r_ar�l ", trout. rarely rr ettia� C:csvc3rag�er Part Ferovige:as a:ov�:rarr�c for °'e3sadily itrojur;y" err "'prct`aer-fy €tarrta{fe" includeai within the "prodsacts- ca'mpteteU ralaerau�ns Y3 e€zs�rr� "_ Ys. il4ltlro rrfsF�ect: tea the insurance :afForded #ero tress addttir�nal ir7sur+ad5. tr€i.s insuranL:� dr3[:b raC'rt erla�rly to "tsradily Fnjury ",. "prrt�aarty e]een'acrr�a" esr "}a�rsuraesl an attverortisin[„s= i'r'i,jury'° errisi €'a� r-rut of the r'an�esrirt� gal', rte. thta ftroilLlre� lira r'ert€icxe-, any prrar�casskoaroett arcktitr3r;- tur�r -, ajrlE�irro:erinc,� ear sueveyinck sere /Ices, inc:Fa.acFn�: (1 j 1"t' €w H /rr��aearirtc�, ¢3&e#art5airty, Crr feaadtlra; tL3 prr:�aaru car appra;.c�„ m�lfas„ sF:pp cir�rvarkn��,.,. ea�airroir�ns,. rexports, survcays,. I�r.:t� crriers, chanr�e: oe•ders. disi�ns r>r• dr35nrin€]s. an.:f specafica #ions, L3r {2) Sup�erwisut'y, inspection,, elrrhilrotural rvr c.a-tr..yD; °iL� �reaacf ar..tir sties. ti3. L►de�ftinraxrof Irtsurecl -• iCo- Citwn ®r of Insarrsd Prctrttisea V'W'FiCi IS Ja.kV ihi�lJF�ED under Sraction C. is earr';rtndr::d Tea nclur�a as ari acldirieanal irasureaf the: person {s;k asr �irc�anization {s;D shcav€rn Fn the CJuc,lar<-atieens -as an Ariditicanr�l insureed ._.. i�c>- C'fwrroe�r C?f irrosurea� f?re3lriisePS, but only with rcros� react tea tFt.�ir IiatallFty as era - yawner cif the pran'aisus s #tovtrn irro thE3 I7ecFaraeions. Par�•Ir� 20 0� 24 Tr€[ro lire €its raf insurar €cce 'treat �al:a;{rly fa ae'►diti[jraat ialsureacys eare� ert:scritaed Frro :aactorr t7. -- i...lnroit� �]f t n s ura rrcet. He:sw #his insurance appfia~s when ather insaaranc4 FS av�llataii3 to an arjditeanal ir€surr.7d 6•a rJexSCri rLaE::r.� in rime C3ttaer Insurance Candtina•a iaro Sec #,iqr€ E. -- Lfabiiity And f�tt3dicat Cx{rE;arosc:s G�nE:re�t �GnCJitiU Ptf:. G. LI�►Bll..l'i"'Y" ANCa fllIEi31t: p. L. E}CPEl�iSES [7EFINITIG7f+lS :. " "r'�dwe�rEsemsnt'° r>•we ;ans Ehei wicir:;�garc.ad j:r[akaYkc;; diSSwrnroinati!on saf infrrorrnatr�:,�:n /ar ima�t;�s trts'�t 'has #ham pur'C.,case csf frtdu;:i€�g tree sa�3c: of i�ctacis, ;preaUuc #S ar Sarricrss tr€rc,u�h; a. (i} �L3dIL7; (.3j Blllb�iaray; !(�� ILliia Ce &i "IrroE3. {rJj i''tiiaVVSIJcrF3£ir; b. Trre3 Internet, but ar €ly that parr ol� � weta sitr3 that is eabouE wads, l-,ntdue:tS nr 5a•3rW.iCeas for the purrras«:s of rndu�i ra cl #f€n sale cat gaeacis. prL� ducts ur sr:rv�icts�; car C. .fir -iy othe2r troutalit;zafcet7 th;�t is �ivrsll 4naidespraad platalir rfiS #rilrL.etic�n.. F- las�etver. "advrartis:r_onle�nt'" d�r?es r•sar in,vtLa.9rr- a. l`I•re deaxign, prinfucf rnrvroc- ::riu1. inficarraaatic.r'; car irx €eal;ieas orsratcrir €ea�_I ira, war•€ ur uK€eart tr€i Fc:�r,N;agiP-rr� ire- I.'�trocilin� c -�t a:r-iY L�-t:€r.3cia� ce3.. Frraduc #a, nr la. .Fhra FnEa?ractive; eeaa7wP~rs�atiun tye:rava�:.r'i csr aerrtrtra� �se;r'�oeros tFroe'_au�Ta a orvr'rrput�^r raa~tw'or4c. 2. ' "RLiwe:.e�i5ing idea" m�;ans early idea fear en ".a.d� ✓c� r1:is ernes nt ". 3. ' °I+sb <= sEC:€r• iaazcarr;`" rroterarts zar'r aa:�;.k.,,asurea csa• threat car expro�ure tea tFroe aartual cro:r allr: �cra:f prafac:rXies e6 astacsstas�: a:€rar�l iraclur]u5 the rart3rea prastance of askeassfcrs !n rz.ny fcarrn 4. ' "itiutcn "' rraeeens :� aand rrsca[ car vas,r€ir::a�, tr�a.il�r o- seeni•traiiaar d<t_ir�nE:ci fcrr- trt�ava�k srrro ksuk��.ki� reads, including any atta+.;kroc:d m.=€c:'hinery car Ese�uiprnant_ But "�a uta "' dra€;.s nat in cr€ad� ' °rauatuidr� eriuipmr;`Irot ".. 5. ,'•Bodily injLrr-y' nroa�sa,s prrySical; a. I eta a ry. b, Sick:r•ausse or c. C3iseast, sus[akrrotrd lay iro p�:rsara anti rf :ari��irat;.l taut a_o-f tlt[: atscrvra„ aroro+:ntal zrongL.€lsh err a�feaath L3rr ,•any time. B. ' °Covar rage tarritar}+" me.€ans; Fvr'm S`S fiW d®: 1)4 iX5 IIIIIII III IIIIIII IIII VIII IIIIII IIII VIII VIII VIII VIII VIII VIII VIII I'lll VIII IIII IIII 'GYBU IAIS/00033WU5 /US /O /O /O /O' r1- 2009 -059 S "Tr1NDAI2ll CONSLJI.. "I'AN•i' AC:12FF.MN:N "I' TI -iIS ACiREEl'v11�i� 1, made and entered into this 1" day oC Junc, 2009 by and beri�cen Rittman Enterprises, LLC, a Culilorniu Limited Liability Company (hcrcinaltcr -'Consultant' "), and the City oi'Santa . <\na, a charter city and municipal corporation organised and exisfin� under the Constitution and laws i�f the State oi' California (hereinafter "City " }. RECITALS A. The City desires to retain a consultant having special skill in providing ambulance and paramedic billing and collection services for the City's Emergency Medical Services Progr4un. B. Consultant represents that Consuhant is able and willing to provide such services to the City. C_ hi undertaking the per£onnance of this Agreemeut, Consultant represents that it iS knowledgeable in its field and that any services perlornted by Consultant under this Agreement will be perfomied in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE. in consideration —C-1- mutual and respective promises, and subject fo the terms and conditions here;inaftcr set forth. the parties agree as follows= SCOPE OF SERVICES Consultant shall provide FMS billing and collection services as set forth in Exhibit .1. attached to this Agreement and incorporated by reference. 2. COMPENSATION City agrees to pay, and Consultant agrees to accept as total payment for its services a fee equal to 631/6 o£net collections obtained by Consultant. 11-at any time during the terra of this Agreement, City implements eI'CR. Consultant payment will be reduced to 6.0% of net collections obtained. Consultant shall bill for Emergency Medical Services at the rates established by City Council Resolution. b. Payment by City shall be made within thirty (30) days following receipt of-proper invoice evidencing collections received by City, subject to City accounting procedures. Payment need not be made 1`ur work which £ails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM `Phis Agreement shall commence on Jtrly 1, 2009 and terminate on June 30, 2012, unless Germinated earlier in accordance with Section 12, below. The term of this Agreement may he extended for one additional two -year term upon a writing executed by the Fire Chief and the City Attorney for the City and by Consultant. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire tern ofthis Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer - employee relationship, a joint venture relationship, or to allow the Citv to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of-this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent %with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement. Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self- insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents. employees, consultants, special counsel, and representatives from liability for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health, and claims for property damage, X ..'hick nzay arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement_ 'rhe Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable reliefdue to personal or property rights arises by WITTENT -01 A�°R ©� CERTIFICATE OF LIABILITY INSURANCE DAT6/25/2012rr) 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. 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 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 Tracy Dolan Wells Fargo Insurance Services USA, Inc. PHONE FAX " ac No Ext): 916 231 -1757 A/C No): 231 -1868 CA DOI Lic. #OD08408 (916) 231 -1741 _916 — - - -- E -MAIL trot . ADDRESS: y dolan @wellsfargo.com 11017 Cobblerock Drive, Suite 100 INSURER(S) AFFORDING COVERAGE NA_IC # Rancho Cordova, CA 95670 -6049 _ _ INSURER A: National Fire Insurance $ 300,000 INSURED INSURER B : National Fire Insurance Company of Hartford 20478 Wittman Enterprises, LLC INSURER C: Hartford Casualty Insurance Company 29424 PO Box 269110 -- - " - - -- -- INSURER D: Evanston Insurance Company 35378 INSURER E - -- $ 2,000,000 Sacramento, CA 95826 INSURER F: COVERAGES CERTIFICATE NUMBER: 4514657 REVISION NUMRER- coo h.1— 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 LTR TYPE OF INSURANCE ADDL SUBR -- - POLICY NUMBER POLICY EFF MM /DDIYYYY POLICY EXP MMIDDIYYYY - -- - — LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY 4034654035 07/01/2012 07/01/2013 EACH OCCURRENCE 2,000,000 _______$ "AGE-TO RENTED PREMISES jEa occurrence) $ 300,000 _ MED EXP (Any one person) $ 10,000 i CLAIMS -MADE i X 1OCCUR PERSONAL & ADV INJURY - -- $ 2,000,000 __ _ GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP /OP AGG $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY E OT- -� LOC " "_- —_..- $ - -_. _ - B AUTOMOBILE LIABILITY ANY AUTO 84012487490 07/01/2012 07/01/2013 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) _ $ Ix ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY ( Per accident ) $ HIRED AUTOS X NON -OWNED AUTOS $ _ PROPERTY DAMAGE Peraccident) $ C X UMBRELLA LIAB X OCCUR 4034654083 07/01/2012 07/01/2013 i EACH OCCURRENCE -- 2,000,000 - EXCESS LIAB � CLAIMS -MADE AGGREGATE $ 2,000,000 DE17 X RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER ? EMBER EXCLUDE ❑ NIA , WC STATU- OTH- LTW11 LIMITS ER " E.L. EACH ACCIDENT - $ - E.L. DISEASE - EA EMPLOYEE — $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below — E.L. DISEASE -POLICY LIMIT - -- - - - - - -- $ D Prof Liability E0850756 07/01/2012 07/01/2013 $1,000,000/$2,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Certificate holder named additional insured per attached form. *10 day notice applies if cancelled for non - payment of premium. % La 1 i Slit City of Santa Ana 1439 Broadway Santa Ana, CA 92701 V VG 11Vnx SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i ne AL urcu name and logo are registered marks of ACORD © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) CNA SB- 146932 -E (Ed. 06111) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - LIABILITY EXTENSION This endorsement modifies Insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM Coverage afforded under this extension of coverage endorsement does not apply to any person or organization covered as an additional insured on any other endorsement now or hereafter attached to this Policy. 1. ADDITIONAL INSURED — BLANKET VENDORS WHO IS AN INSURED Is amended to include as, an additional insured any person or organization (referred to below as vendor) with whom you agreed, because of a written contract or agreement to provide insurance, but only with respect to "bodily injury' or "property damage" arising out of "your products" which are dlstributed or sold In the regular course of the vendor's business, subject to the following additional exclusions: 1. The Insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of Inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such Inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make In the usual .course of business, In connection with the distribution or sale of the products; f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or h. "Bodily Injury" or "property damage" arising out of the sole negligence of the vendor for its SB- 146932 -E (Ed. 06111) own acts or omission or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to; (1) The exceptions contained in Subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, In connection with the distribution or sale of the products. 2. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. 3. This provision 2. does not apply to any vendor included as an Insured by an endorsement issued by us and made a part of this Policy. 4. This provision 2. does not apply if "bodily injury" or "property damage" included within the "products - completed operations hazard" is excluded either by the provisions of the Policy or by endorsement. 2. MISCELLANEOUS ADDITIONAL_ INSUREDS WHO IS AN INSURED Is amended to Include as an Insured any person or organization (called additional insured) described in paragraphs 2.a. through 2.h. below whom you are required to add as an additional Insured on this policy under a written contract or agreement but the written contract or agreement must be: 1. Currently in effect or becoming effective during the term of this policy; and 2. Executed prior to the "bodily injury," "property damage" or "personal and advertising injury," but Only the following persons or organizations are additional insureds under this endorsement and coverage provided to such additional insureds is limited as provided herein: a. Additional Insured —Your Work That person or organization for whom you do work is an additional insured solely for liability Page 1 of 5 CNA due to your negligence specifically resulting from your work for the additional Insured which is the subject of the written contract or written agreement. No coverage applies to liability resulting from the sole negligence of the additional insured. The insurance provided to the additional insured is limited as follows: (1) The Limits of Insurance applicable to the additional insured are those specified In the written contract or written agreement or in the Declarations of this policy, whichever Is less. These Limits of Insurance are inclusive of, and not In addition to, the Limits of Insurance shown in the Declarations. (2) The coverage provided to the additional insured by this endorsement and paragraph F.9, of the definition of "insured contract" under Liability and Medical Expenses Definitions do not apply to "bodily injury" or "property damage" arising out of the "products- completed operations hazard" unless required by the written contract or written agreement. (3) The insurance provided to the additional insured does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of the rendering or failure to render any professional services. b. State or Political Subdivisions A state or political subdivision subject to the following provisions: (1) This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit In connection with premises you own, rent, or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (2) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. SB- 146932 -E (Ed. 06111) SB- 146932 -E (Ed. 06111) This Insurance does not apply to "bodily injury," "property damage" or "personal and advertising Injury" arising out of operations performed for the state or municipality. c. Controlling Interest Any persons or organizations with a controlling interest in you but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for such additional insured. d. Managers or Lessors of Premises A manager or lessor of premises but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the premises leased to you and subject to the following additional exclusions: This Insurance does not apply to: (1) Any 'occurrence" which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such additional Insured. e. Mortgagee, Assignee or Receiver A mortgagee, assignee or receiver but only with 'respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of a premises by you. This insurance does not apply to structural alterations, new construction or demolition operations performed by or for such additional insured. f. Owners /Other Interests — Land is Leased An owner or other interest from whom land has been leased by you but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the land leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any 'occurrence" which takes place after you cease to lease that land; or Page 2 of 5 CNA S (Ed. 06/11) (E . 06/11) (2) Structural alterations, new Damage To Property, Is replaced by the construction or demolition operations following: performed by or on behalf of such additional insured. k. Damage To Property g p y g. Co -owner of Insured Premises "Property damage" to: A co -owner of a premises co -owned by you 1. Property you own, rent or occupy, and covered under this Insurance but only including any costs or expenses with respect to the co- owners liability as co- incurred by you, or any other person, owner of such premises. organization or entity, for repair, replacement, enhancement, h. Lessor of Equipment restoration or maintenance of such Any person or organization from whom you property for any reason, Including lease equipment. Such person or organization prevention of injury to a person or are insureds only with respect to their liability damage to another's property; arising out of the maintenance, operation or 2. Premises you sell, give away or use by you of equipment leased to you by abandon, if the "property damage" such person or organization, A person's or arises out of any part of those organization's status as an Insured under this premises; endorsement ends when their written contract or agreement with you for such leased 3. Property loaned to you; equipment ends. 4. Personal property in the care, With respect to the insurance afforded these custody or control of the insured; additional Insureds, the following additional 6. That particular part of any real exclusions apply: property on which you or any This insurance does not apply: contractors or subcontractors working directly or indirectly in your behalf are (1) To any "occurrence" which takes place performing operations, If the "property after the equipment lease expires; or damage" arises out of those (2) To "bodily injury," "property damage" or operations; or "personal and advertising Injury' arising 6. That particular part of any property out of the sole negligence of such that must be restored, repaired or additional insured. replaced because "your work" was Any insurance provided to an additional insured incorrectly performed on It. designated under paragraphs b. through h. above Paragraph 2 of this exclusion does not does not apply to "bodily Injury" or "property apply if the premises are "your work" and damage" included within the "products- completed were never occupied, rented or held for operations hazard." rental by you. 3. The following is added to Paragraph H. of the Paragraphs 1, 3, and 4, of this exclusion BUSINESSOWNERS COMMON POLICY do not apply to "property damage" (other CONDITIONS: than damage by fire or explosion) to H. Other Insurance premises: 4. This insurance is excess over any other (1) rented to you: insurance naming the additional insured (2) temporarily occupied by you with the as an Insured whether primary, excess, permission of the owner, or contingent or on any other basis unless a (3) to the contents of premises rented to written contract or written agreement you for a period of 7 or fewer specifically requires that this insurance be consecutive days. either primary or 'primary and noncontributing. A separate limit of insurance applies to Damage To Premises Rented To You as 4. LEGAL LIABILITY— DAMAGE TO PREMISES described in Section D — Liability and A. Under B. Exclusions, 1. Applicable to Medical Expenses Limits of Insurance. Business Liability Coverage, Exclusion k. SB- 146932 -E Page 3 of 6 (Ed. 06/11) CHA Paragraphs 3, 4, 5, and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph 6 of this exclusion does not apply to "property damage" included In the "products- completed operations hazard," B. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the last paragraph of 2. Exclusions Is deleted and replaced by the following: Exclusions c, d, e, f, g, h, I, k, I, m, n, and o, do not apply to damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner or to the contents of premises rented to you for a period of 7 or fewer consecutive. days. A separate limit of insurance applies to this coverage as described in Section D. Liability And Medical Expenses Limits Of Insurance. C. The first Paragraph under item 5. Damage To Premises Rented To You Limit of Section D. Liability And Medical Expenses Limits Of Insurance Is replaced by the following: The most we will pay under Business Liability for damages because of "property damage" to any one premises, while rented to you, or temporarily occupied by you, with the permission of the owner, including contents of such premises rented to you for a period of 7 or fewer consecutive days, is the Damage to Premises Rented to You limit shown in the Declaration. 5. Blanket Waiver of Subrogation We waive any right of recovery we may have against: a. Any person or organization with whom you have a written contract that requires such a waiver. 6, Broad Knowledge of Occurrence The following items are added to E. Businessowners General Liability Conditions in the Businessowners Liability Coverage Form; 9. Paragraphs a. and b. apply to you or to any additional insured only when such "occurrence," offense, claim or "suit" Is known to: (1) You or any additional Insured that is an individual; SB- 146932 -E (Ed. 06111) SB- 146932 -E (Ed. 06/11) (2) Any partner, if you or an additional insured Is a partnership; (3) Any manager, if you or an additional insured is a limited liability company; (4) Any "executive officer" or insurance manager, if you or an additional Insured is a corporation; (5) Any trustee, if you or an additional Insured is a trust; or (6) Any elected or appointed official, if you or an additional insured is a political subdivision or public entity. This paragraph e. applies separately to you and any additional insured. 7. Bodily Injury Section F. Liability and Medical Expenses Definitions, Item 3. 'Bodily Injury" is deleted and replaced with the following: "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death, humiliation, shock, mental anguish or mental injury by that person at any time which results as a consequence of the bodily injury, sickness or disease. 8. Expanded Personal and Advertising Injury Definition a. The following is added to Section F. Liability and Medical Expenses Definitions, Item 14. Personal and Advertising Injury, In the Businessowners General Liability Coverage Form: h. Discrimination or humiliation that results In injury to the feelings or reputation of a natural person, but only if such discrimination or humiliation Is: 1. Not done intentionally by or at the direction of. a. The Insured; or b. Any "executive officer.," director, stockholder, partner, member or manager (if you are a limited liability company) of the insured; and 2. Not directly or indirectly related to the employment, prospective employment, past employment or termination of employment of any person or person by anyinsured. b. The following is added to Exclusions, Section B.. Page 4 of 5 C'NA (15) Discrimination Relating to , Room, Dwelling or Premises Caused by discrimination directly or Indirectly related to the sale, rental, lease or sub -lease or prospective sale, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured. (16) Fines or Penalties Fines or penalties levied or imposed by a governmental entity because of discrimination. c. This provision (Expanded Personal and Advertising Injury) does not apply If SB- 146932 -E (Ed. 06111) SB- 146932 -E (Ed, 06111) Personal and Advertising Injury Liability Is excluded either by the provisions of the Policy or by endorsement. 9. Personal and Advertising Injury Re- defined Section F. Liability and Medical Expenses Definitions, item 14, Personal Advertising Injury, Paragraph c. Is replaced by the following: 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 or organization occupies committed by or on behalf of It's owner, landlord or lessor. Page 5 of 5 �.•�� WITTENT -01 SJENKINS AC`�RQ DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE _ 6/1912012 j 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 i REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. _ IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must 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 License # OG98480 —_ CONTACT Western Elite Insurance Solutions PHONE 9l6) 259 -6900 �l FAX, No): (866 206 -8646 PO Box 2980 LAIC. No. Extra (- ! —_.._ Li __..__. E -MAIL Rocklin, CA 95677 ADDRESS:_, INSURERfSI AFFORDING COVERAGE NAIC p INSURED Wittman Enterprises LLC PO Box 269110 Sacramento, CA 95826 COVERAGES CERTIFICATE NUMBER: INSURER 0: INSURER 0:_ Granite State Insurance 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 VMTH 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 - - -- -- "- " - "- - � "DL $UBk- _- -- -- -"�POLICY EFF POLICY E %P LIMITS TYPE OF INSURANCE_ _ _ P_O_LI_CY NUMBER IMMIDDIYYYY_J (MM100IYYYYI LTR ---- - - -... _ GENERAL LIABILITY - COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-1 OCCUR . �i ,';�' 'WL, ! •° 'r ��_ '� \ -" - ? f.`'� ' .. - , EACH OCCURRENCE S "6A- i�7fAUc T6RER7E0 -PREMISES _(Ea occurrence ME EXP (Any one person) - PERSONAL SADV INJURY S -- GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER POLICY [:J �R� LOC � AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _ AUTOS _ . AUTOS NON-OWNED - -. ",- HIRED AUTOS - AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CIAIMSWADE PROOUCTS-COMP /OP AGG .._._.. ._ S — -_ COMBINED SINGLE LIMIT _(Ea accident )" —._ $ 1-- BODILY INJURY (Per person) 5 BODILY INJURY (Per accident] $ PROPERTY DAMAGE $ EACH OCCURRENCE 5 $ AGGREGATE - S DED I RETENTIONS A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN N OFFICERIMEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA C065256372 7/112012 711/2013 x WC STATU- OTH- T RV LIMIT _ k E.L. EACH ACCIDENT ' 000 E.L. DISEASE - EA EMPLOYEd .1,000,000 S 1,000,000 E.L. DISEASE -POLICY LIMIT S _ - 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) The City of Santa Ana 1439 S. Braodway Santa Ana, CA 92707 111NJYI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD