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Home My WebLink AboutSUAREZ, RAYMUNDO 2dCity of Santa Ana Clerk of the Council AGREEMENT TERMINAYION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M -30). Call 647 -6520 if you have any questions. The agreement with Suarez, Raymundo G 200b COTC Office Use Only No N -2005 -101 was completed on 6/30/06 and final payment has been made. (List all amendments. Use space below if needed.) N- 2005 - 101-01, N- 2005 - 101 -02, N- 2005 - 101 -03, Department: PRCSA N- 2005 - 101 -04, N- 2005 - 101 -05, N- 2005 -101 -006 N- 2005 -101 -007 Phone /Ext.: 5254 Signature: a CiAJ lfSl 21 Date: 6/16/14 Revised 08 -23 -10 INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES N- 2005 - 101 -04 Ix -,31 - C, CLERK OF COUNCIL DATE: �% N L C -- FOURTH AMENDMENT TO AGREEMENT THIS FOURTH AMENDMENT TO AGREEMENT is made and entered into this 3`d day of June 2009 by and between the City of Santa Ana, a charter city and municipal corporation of the State of California ( "City ") and RAYMUNDO SUAREZ ( "Consultant "). RECITALS: 1. City and Consultant entered into Agreement N- 2005 -101, dated June 1, 2005, Amendment N- 2005 - 101 -01 dated May 15, 2006, Amendment N- 2005- 101 -02 dated April 19, 2007, and Amendment N- 2005- 101 -03 dated May 29, 2008 (hereinafter "said Agreement ") by which Consultant has instructed self defense classes through the City's leisure class program. 2. In accordance with the terms and conditions of said Agreement, the parties wish to renew the said Agreement for an additional one -year period and amend the Scope of Services to reflect increased fees for the classes. WHEREFORE, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this Fourth Amendment to Consultant Agreement, the parties agree as follows: Section 1. SCOPE OF SERVICES, shall be amended by replacing Exhibit A, attached to said Agreement, with Exhibit A -2, attached hereto. 2. Section 3, TERM, shall be amended to extend the term of said Agreement through June 30, 2010. Except as herein amended, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, City and Consultant have executed this Fourth Amendment to Agreement on the day and year first set forth above. ATTEST: Maria D. Huizar Clerk of the Council Signatures continued on next page CITY OF SANTA ANA DAVID N. ftEAM City Manager APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney By: Kylee Otto ' Assistant City Attorney RECOMMENDED FOR APPROVAL: By: A GERARDO MOUET, Exe utive Director Parks, Recreation and Corhmunity Services CONSULTANT '. y .. Suarez EXHIBIT A -2 SCOPE OF SERVICES 1. Consultant will prepare and instruct students in martial arts techniques, with an emphasis on Jujitsu for children and adults, 6 and older. 2. Consultant will confer with the City to set the times and location of the classes, including days and hours of class and holidays to be observed. The City reserves the right to preempt any class as City deems necessary. Thirty (30) day notice of such change will be provided, if possible. Instructor may reschedule any class which has bee preempted. 3. Consultant will provide and be responsible for equipment, records, personnel and clean up of the facilities and materials necessary to ensure the safety and effectiveness of said instruction. 4. If Consultant allows others to teach his/her class, those teachers must be over 21, have obtained and maintain an instructor rating, and be covered by Consultants' insurance. Consultant shall provide City with documentation to verify instructor and insurance requirements. Black -belt rated students may warm up beginning students, however, Consultant must be present at all times. CLASS SIZE REGISTRATION 1. The minimum number or participants is 5 per class, the maximum is 30. 2. No registration will be accepted after the second week of classes. 3. In the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Consultant will be under no obligation to provide services and the City will have no obligations to pay Consultant compensation. FEES 1. Each participant shall pay a $15.00 class registration fee per monthly session. 2. No refunds will be made to participants after the commencement of a session unless the class is cancelled by the City. 3. The City shall collect registration fees from each participant during the registration period. Consultant shall not collect fees, but shall refer all interested participants to City for registration. 4. Consultant shall receive seventy per cent (70 %) of the total fees collected each month. City and Consultant agree that City shall retain thirty per cent (30 %) of the fees collected as an administration fee. 5. Consultant agrees that City is entitled to audit Consultant's records and classes to insure compliance with this Agreement. 6. Consultant may not waive class participation/registration fees. 7. City shall prepare class rosters and provide a copy to Consultant. Only registered participants may participate in class. N- 2005 - 101 -04 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2009 -31 CERTIFICATE OF INSURANCE EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS, SPECIAL EVENT LIABILITY PROGRAM PRODUCER: PUBLIC ENTITY (ADDITIONAL INSURED) City of Santa Ana Alliant Insurance Services, Inc. in conjunction with 20 Civic Center Plaza Apex Insurance Services Santa Ana, CA 92701 P. O. Box 6450 Newport Beach, CA 92658 (949) 660 -8135 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Raymundo Suarez TYPE: Martial Arts 610 S. Townsend Street DAT$(S): September 1.2009 - December 31, 2009 Santa Ana, CA 92703 LOCATION: El Salvador Recreation Center *Liquor Liability Yes ❑ No "Liquor Liabili after 12 amends before 2 am ❑ 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 requirements, terns or conditions of any contract oi• 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. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: 04SEP100000I -5 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2009 EXPIRATION: JANUARY i, 2010 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 11000,000 Personal & Advertising Injury 1,000,000 Each OccutrcnccLimit 1,000,000 Fire Damage (Any One Fire) 50,000 Medical Payments (Any Ono Person) 5,000 Liquor Liability (If purchased) 1,000,000 The limits of Insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. "Who is insured" is amended to include, as an insured, the person or organization shown in this schedule, but only with respect to liability arising outof the ownership, maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any "occurrence" which takes place after the event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS o ILIA A,P13 � - t Sheed Y a - /Lau rn,y Assistant. CANCELLATION: Should the above described policy to cancelled before the expiration date thereof, the issuing company will mail 30 days written notice to the certificate holder and additional insureds listed. AUTHORIZED REPRESENTATIVE: DATE ISSUED: — _ September 1. 2009 4 ACDRD TM. CERTIFICATE AF LIABILITY INSURANCE OATS (MIUDD/YYYY) ornsnoDe PRODUCER Phase: f&") 3S'1"75 F.. (am 4n4$10 1913 09RTIFiCA7E IS ISSUED AS A MATTER OF INFORMATION FITHESSAND WELLNESS ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE 380 STEVENS AVENUE, SURE 200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR SOLANA BEACH CA 92075 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- 5 AFFORDING COVERAGE NAIL 0 A: Philadelphia rndamnitylnsuranosCompany I fao if Raymundo Suarez NSURER B: 010 S Townsend Suest NSURER C: Santa Ana CA 92703 NSURER D: O 1 EXPIRATION DATE 04= SURER E: THE POLICIES Of INSURANCE LISTED BELOTI HAVE BEEN 13SUEDFQ7HE INSURED NAI ED ABOVE R PERIOD INDICATED. N0TL jIITfi$TAN0jNG Y REOUIREMENT, 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. 045 LTR kwi N9 TYPE Of INSURANCE POIICY NVNBBR POLICY OFF60TIVE DA7E (A UMMY) O 1 EXPIRATION DATE 04= MNns GENERAL LIABILITY PHPK430634 0712812009 05118/2010 EACH OCCURRENCE 1,000,000 X COMMERCIAL GENERAL LIABILITY lA1MS MADE OCCUR AMAGETORENTEOPREMISE9 Ea ae"cua] $100,00 ED. EXP (Any one person) $2,80 A X X PROFESSIONALLIARILITY ER30?1ALE,ADVINJURY 1,000,000 GENERAL AGGREGATE S 3,000,000 EN'L AGGREGATE LIMIT APPLIES PER: RODUCTS•COMPIOPAGO. S 3,000,000 ' X OLICY ROJ• OC CT AUTOMOBILE LIABILITY OMBINED SINGLE LIMIT NYAUYO Ea acdden0 9 lL OWNED AUTOS 30DILYINJURY CHEDULEO AUTOS Par person) IRED AUTOS 0DILY INJURY ON•OW NED AUTOS Per as4den0 ROPERTY DAMAGE ��Z. rrll V Per accident) ARAGE LLABILITY NY AUTO �,�.�R(3i UTO ONLY- CA ACCIDENT THER THAN EA ACC UTO ONLY: AGO EXCESS I UMBRELLA LIABILITY CCUR DLANAS MADE L"M •0_V «mot EACH OCCURRENCE AGGREGATE _ EDUCTteLE ETENTION $ )AB ILITY ROPRIETORIPARTNEMBXECVTIVE ORKERSCOMPENSATIONANDEMPLOYERS' Y PMER&EASER EXCLUOEM YwC l i8 T HR �-L- EACH ACCIDENT s, 4axroe oder SPECIAL PROVOH5 lw DISEASE- .17i MIT HER: DESCRIPTION OF OPERATION ILOCATIONSIVE 1C SIEXCLUSIO SADDED BY NDORSEMENTI SPECIAL PROY1 10 3 It Is understood and agreed that the following amity: City of Santa Ana, Its Officers, Employers, Agents, Volunteers d Representatives are added as an additional Insured but only as respwte The operations of the named Insured except That liability resulting from the additional Insureds solo negligence. vu1u1 ,-rrrc rlV6U CR CGNr:FI i &TIrllll City of Santa Ana 20 CHID Cantor Plsre Santa Ana. CA, 92)01 SHOULD ANY OF THE ABOVE DESCRIBED PO ICIES Be CANCELLED BEFORE THE EXPIRATION GATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS YMITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT'S AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE Attention: M"'Jmu z� (xUU IJz) Certificate 4 84562 ACORD CORPORATION 1868 POLICY CHANGE DOCUMENT POLICY NO.: PHPK430634 Philadelphia Indemnity Insurance Company Unassigned (SB) NAMED INSURED Raymundo Suarez MAILING ADDRESS 610 S Townsend Street Santa Ana, CA, 92703 POLICY PERIOD: FROM 06/15/2009 TO 06/15/2010 at 12:01 A.M. Standard Time at your mailing address shown above CHANGE EFFECTIVE 07/28/2009 CHANGE # 1 DESCRIPTION Add Additional Insured: CITY OF SANTA ANA 20 CIVIC CENTER PLAZA SANTA ANA CA 92701 Path ID: 3831263 Total Annual Additional /Return Premium COUNTERSIGNED $0.00 Total Prorate Additional /Return Premium $172.00 (Date) BY Page 1 of 1 (Authorized Representative) Philadelphia Indemnity Insurance Company One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 COMMON POLICY DECLARATIONS Policy Number: PHPK430634 Named Insured and Mailing Address: Producer: Raymundo Suarez Unassigned (SB), 6039 610 S Townsend Street 26300 LA LALMEDA Santa Ana, CA, 92703 MISSION VIEJO CA 92691 US Policy Period From: To: 06/15/2009 06/15/2010 at 12:01 A.M. Standard Time at your mailing address shown above. Business Description: Individual IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part Commercial General Liability Coverage Part $122.00 Commercial Crime Coverage Part Commercial Inland Marine Coverage Part Commercial Auto Coverage Part Businessowners Workers Compensation Taxes /Fees /Surcharges $50.00 Total $172.00 FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE Refer To Forms Schedule Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations CPD- PIIC (01/07) &q- Countersignature Date Authorized Representative Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Policy Number: PHPK430634 ® See Supplemental Schedule LIMITS OF INSURANCE $3,000,000 $3,000,000 $1,000,000 $1,000,000 $100,000 $2,500 Agent # 6039 General Aggregate Limit (Other Than Products — Completed Operations) Products /Completed Operations Aggregate Limit (Any One Person Or Organization) Personal and Advertising Injury Limit Each Occurrence Limit Rented To You Limit Medical Expense Limit (Any One Person) FORM OF BUSINESS: INDIV Business Description: Individual Location of All Premises You Own, Rent or Occupy: AUDIT PERIOD, ANNUAL, UNLESS OTHERWISE STATED: SEE SCHEDULE ATTACHED Classifications Code No. Premium Basis Rates Prem./ Ops. Prod./ Comp. Ops I Advance Premiums Prem./ Prod./ Ops. Comp. Ops. SEE SCHEDULE ATTACHED TOTAL PREMIUM FOR THIS COVERAGE PART: $122.00 INCLUDED RETROACTIVE DATE (CG 00 02 ONLY) This insurance does not apply to 'Bodily Injury", "Property Damage ", or "Personal and Advertising Injury" which occurs before the retroactive date, if any, shown below. Retroactive Date: FORM (S) AND ENDORSEMENT (S) APPLICABLE TO THIS COVERAGE PART: Refer To Forms Schedule Countersignature Date Authorized Representative