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HomeMy WebLinkAboutCHAU, ANN INSURANCE NOT ON FILE N-2025-127 WORK MAY NOT PROCEED CITY CLERK a:. DATE. MAY 2 2 2025 May 8,2025 Ann Chau("Speaker/Performer") 4759 Lakewood Blvd. Lakewood, CA 90712 Ciaochau86(agmail.com 1���1aa, DL nU ilG � Re: Speaker/Performer Engagement A Bement This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: 1. Event Description: As further described in Exhibit A, attached hereto, Speaker/Perfonner shall provide a presentation and reading of their book,My Ong Ngoai's Garden.They will also provide a Q&A as well as materials including copies of their book,bookmarks, and coloring sheets of various Vietnamese tropical fruits for raffle and giveaway once the presentation concludes. 2. Date(s): Friday, May 23, 2025 3. Event Time(s): 3:00 p.m.—4:00 p.m. 4. Location("Property"): Santa Ana Public Library,Newhope Branch, 122 N Newhope St., Santa Ana, CA 92703 5. Compensation: $500 (payable by check within 30 calendar days of event); Speaker/Performer must provide IRS form W-9 before payment can be made . 6. Provided by City: space for the event(s),microphone,projector,tables and chairs. 7. Provided by Speaker/Performer: All other equipment and materials necessary. 8. City Contact Person(for coordinating purposes only): Dario Dylan x5118 9. Independent Contractor: Speaker/Performer shall, during the entire tern 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 Speaker/Performer performs the services that are the subject matter of this Agreement, however, the services to be provided by Speaker/Performer shall be provided in a manner consistent with all applicable standards and regulations. Speaker/Performer 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. 10. Speaker/Performer shall procure and maintain for the duration of this Agreement, the insurance requirements as further detailed in Exhibit B, attached hereto. 11. Indemnification: Speaker/Performer,his or her agents,or employees(if applicable)agrees to and shall indemnify, defend,and hold harmless the City,its officers,agents,employees,consultants,special counsel,and representatives from and against all loss, expenses, or liability (including costs and attorney's fees)arising from the negligence or willful misconduct of Speaker/Performer,his or her agents, or employees. Speaker Agreement—Ann Chau Page 2 13. Release: Speaker/Performer accepts any City-provided equipment used in connection with the performance in their "as-is" condition, with all faults. Speaker/Performer fully releases, waives and discharges forever any and all claims,demands,rights,and causes of action of any kind or nature against,and covenants not to sue,City,its elected officials, officers,employees, agents and volunteers,and all persons acting on behalf of,by,through or under each of them,under any present or future laws,statutes, or regulations for any claim or event relating to the condition of the City-provided equipment or Speaker/Performer's use thereof. 14. The City shall have the right and royalty-free license to simulcast or produce and show a tape-delayed broadcast of Speaker/Performer's presentation to the City community or general public, through webeast or any other means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Performer. Copies of Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such recordings. 15. Speaker/Performer is solely responsible for payment of royalty fees, performance fees, or similar fees that may be required by unions or similar organizations. Speaker/Perfonmer shall indemnify the City against any liability or damages, including attorney's fees,that may arise as a result of violation by Speaker/Performer of copyright laws. 16. Speaker/Performer shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection with any activities related to this Agreement. 17. This Agreement shall in all respects shall be interpreted,enforced,and governed exclusively by and under the laws of the state of California. Both parties 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. is. This Agreement represents the complete and exclusive statement between the City and Speaker/Performer regarding the subject matter herein and supersedes any and all other agreements, oral or written,between the parties. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Speaker/Performer. CITY OF TA ANA SPEAKERTERFORMER �1 Ann Chau(May 9,202514:10 PDT) Alvaro Nunez Ann Chau City Manager ATTEST: APPROVED AS TO FORM: nnifer L. lI Br on Salvatierra City C Deputy City Attorney RECOMMENDED FOR APPROVAL Brian Sternberg Library Services Director Library Services EXHIBIT A SCOPE OF SERVICES VENDOR INFORMATION: Name: Ann Chau Address: 4759 Lakewood Blvd Lakewood, CA 90712 Phone Number: 562-253-8029 Email Address: ciaochau86@gmail.com EVENT: Asian American Pacific Islanders Heritage Month with author Ann Chau. This is a one-time event. LOCATION: Santa Ana Public Library,Newhope Branch, 122 N Newhope St, Santa Ana, CA 92703 DATE: (Preferred): Friday- May 23, 2025—3:00-4:00 p.m. COMPENSATION: $500 DESCRIPTION: To celebrate the Asian American Pacific Islanders Heritage Month during the month of May,the acclaimed children author of My Ong Ngoai's Garden will join us and discuss her book. In My Ong Ngoai's Garden, we follow Cal and.learn about the amazing and delicious, tropical fruits of Vietnam. o We will listen to the author reading her book(or a portion of the book) • Attendees have a chance to participate in Q&A session with the author • Free copies of the book will be raffled off(depends on availability) + There will be bookmarks giveaway, coloring sheets of various Vietnamese tropical fruits EXHIBIT B Contractor shall procure and maintain for the duration of the agreement, the following insurance coverages: MINIMUM SCOPE AND LIMIT OF INSURANCE Contractor shall maintain limits of insurance coverage in the following minimum amounts and shall be at least as broad as: • Commercial General Liability(CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal &advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. • Automobile Liability (AL): Insurance Services Office Form CA 00 01 covering Code 1 (any auto), with combined single limits of $1,000,000. In the event Contractor does not maintain commercial automobile liability insurance, City will accept evidence of personal automobile insurance with existing limits, which can be lower than $1,000,000. If Contractor maintains broader coverage and/or higher limits than the minimums shown above, City requires and shall be entitled to the broader coverage and/or the higher limits maintained by Contractor. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to City. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions: 1. CGL, SAML and AL policies: City of Santa Ana, its City Council, its officers, officials, employees, agents, and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Permittee including materials, parts, equipment, and personnel furnished in connection with such work or operations. 2. All required insurance policies: Insurance company(ies) agrees to waive all rights of subrogation against City, its City Council, its officers, officials, employees, agents, and volunteers for losses paid under the terms of any policy which arise from work performed by Permittee for City. 3. All required insurance policies: For any claims related to this contract, Permittee's insurance coverage shall be primary and any insurance maintained by City, its City Council, its officers, officials, employees, agents, or volunteers shall not contribute with it. 4. All required insurance policies: A severability of interest provision must apply for all the additional insureds, ensuring that Permittee's insurance shall apply separately to each insured against whom a claim is made or suit is brought, except with respect to the insurer's limits of liability. 5. Each insurance policy required herein shall provide that coverage shall not be canceled, suspended, voided, reduced in coverage or in limits, non-renewed by the carrier, or materially changed except after thirty(30) days prior written notice has been given to City. Ten (10) days prior written notice shall be provided to City for policy cancellation or non-renewal due to non-payment. 6. Certificate Holder on each Evidence of Insurance certificate shall be: City of Santa Ana, Attention: (Name of Department Staff Responsible for Agreement), Address of Department Responsible for Agreement, M-XX, Santa Ana, CA 92701. The name and location of event should be included in the Description of Operations section of each certificate. Self-Insured Retentions Self-insured retentions must be declared to and approved by the City. City may require Contractor to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. Acceptability of Insurers Insurance is to be placed with insurers authorized to conduct business in the state of California with a current A.M. Best rating of no less than A:VII, unless otherwise acceptable to City. Verification of Coverage Permittee shall furnish City with original Certificates of Insurance including all required amendatory endorsements(or copies of the applicable policy language effecting coverage required by this clause)and a copy of the Declarations and Endorsement Page of the CGL policy listing all policy endorsements to Entity before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive Permittee's obligation to provide them. City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. Claims Made Policies If any of the required policies provide coverage on a claims-made basis: 1. The retroactive date must be shown and must be before the date of the contract or the beginning of work. 2. Insurance must be maintained and evidence of insurance must be provided for at least three (3) years after completion of work. 3. If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with a retroactive date prior to the contract effective date, Company must purchase "extended reporting" coverage for a minimum of three (3) years after completion of work. Subcontractors Contractor shall require and verify that all sub-contractors maintain insurance meeting all the requirements stated herein, and Contractor shall ensure that City is an additional insured on insurance required from sub-contractors. Special Risks or Circumstances City reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. Speaker-Performer Agreement—Ann Chau (May 2025) APPVD AS TO FORM Final Audit Report 2025-05-09 Created: 2025-05-08 By: Dylan Dario(ddario@santa-ana.org) Status: Signed Transaction ID: CBJCHBCAABAA7X3DKakgBQ013npTpzNuzeTv5G13Wep6 "Speaker-Performer Agreement—Ann Chau (May 2025) APPVD AS TO FORM" History Document created by Dylan Dario (ddario@santa-ana.org) 2025-05-08-10:47:52 PM GMT Document emailed to Brian Sternberg (bsternberg@santa-ana.org)for signature 2025-05-08-10:47:56 PM GMT 'L) Email viewed by Brian Sternberg (bsternberg@santa-ana.org) 2025-05-08-11:03:27 PM GMT &0 Document e-signed by Brian Sternberg (bsternberg@santa-ana.org) Signature Date:2025-05-08-11:03:53 PM GMT-Time Source:server C,• Document emailed to Ann Chau (ciaochau86@gmail.com)for signature 2025-05-08-11:03:55 PM GMT `i Email viewed by Ann Chau (ciaochau86@gmail.com) 2025-05-09-9:08:53 PM GMT G� Document e-signed by Ann Chau (ciaochau86@gmail.com) Signature Date:2025-05-09-9:10:09 PM GMT-Time Source:server Agreement completed. 2025-05-09-9:10:09 PM GMT Adobe Acrobat Sign CERTIFICATE OF INSURANCE ENDORSEMENT SPECIAL EVENT LIABILITY GROUP INSURANCE TRUST,A RISK PURCHASING GROUP Certificate# 51086 FACILITY OWNER-Additional Insured: (if multiple,continued PRODUCER: CA License#0757776 on next page) HUB International Insurance Services Inc. City of Santa Ana,its officers,officials,employees and volunteers,20 3000 Executive Parkway,Suite 300 Civic Center Plaza,Santa Ana,CA 92701 San Ramon,CA 94583 PH:925 609 6547 FX:925 609 6550 specialevent(c)hubinternational.com EVENT HOLDER-Named Insured: (if multiple,continued on EVENT INFORMATION next page) Santa Ana Public Library,City of Santa Ana TYPE OF EVENT: Vendor(1) 20 Civic.Ctr Plaza EVENT DATE(S): 5/23/2025 Santa Ana,CA 92701 EVENT LOCATION(S): Newhope Public Library-122 N Newhope Street,Santa Ana,CA 92703 This is to certify that the policies of insurance listed below have been issued to the insured named above for the event date(s)indicated above. 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. INSURER A: COLONY INSURANCE COMPANY INSR LTR Type of Insurance Policy Number Effective Expiration Policy Limits Each Occurrence $1,000,000 General Aggregate $2,000,000 Personal&Advertising Injury $1,000,000 Products/Completed Operations $2,000,000 Commercial Aggregate A 103 GL 0021111 1/1/2025 1/1/2026 General Liability Damage to Premises Rented to You $1,000,000 Medical Payments $5e 000 Liquor Liability Each Occurrence (Aggregate included in General n/a Liability Aggregate) COVERAGE TERMS: Tu Tra n DuOTralny signed Nguyenby APPROVED Occurrence Form(CG 0001) Date:2025.05.15 Nguyen 11:18:34-07'00' By Tu Tran Nguyen at 11:18 am,May 15,2025 The coverage afforded by this insurance is primary and non-contributing with any Host Liquor Liability Included. insurance held by the "Additional Insured" as Named Insured, when the "Additional Insured" is shown on this Certificate of Insurance Endorsement as "Additional Insured" Full Liquor Liability Included when a or WHEN REQUIRED BY WRITTEN CONTRACT. separate premium has been charged. COVERAGE EXCLUSIONS:(REFER TO POLICY FOR COMPLETE LISTING OF EXCLUSIONS) Communicable Diseases Specific Events are excluded from coverage. Please see second page for list of excluded events. Sexual Abuse&Molestation --Terrorism On behalf of the Risk Purchasing Group and each Member,the Trustee has declined coverage for the Terrorism Risk Insurance Act(TRIA). —Additional Insureds,next page— Second Page of Certificate Certificate# 51086 OTHER ADDITIONAL INSUREDS: 1 Ann Chau-4759 Lakewood Blvd Lakewood,CA 90712 2 3 4 5 6 7 8 9 10 11 12 13 CANCELLATION: Should the above described policy(s)be canceled before the expiration date thereof,the issuing company will endeavor to mail 30 days written notice to the insured event holder and additional insureds listed. AUTHORIZED REPRESENTATIVE: DATE ISSUED: 5/12/2025 Third Page of Certificate Certificate# 51086 SPECIFIC EVENT EXCLUSIONS The following types of events are specifically excluded and no coverage for them exists on the policies listed on the front page of this Certificate of Insurance: Aircraft/Aviation All Terrain Boarding Ballooning /Balloon Rides Base Jumping Bouldering Events Boxing,Wrestling Bungee Jumping Carnival Rides Circuses Concerts with single performances exceeding 6 hours of performance time Contact Karate /Martial Arts Contact Sports Diving Football (except passing camps with no contact drills) Hang Gliding Hockey Jousting Kayaking, Rafting or Canoeing in greater than Class 3 rapids Lacrosse /Rugby Mechanical Amusement Rides or Services and Gyroscope Rides Motorized Sporting Equipment Mosh Pits Mountain Biking Power Boat Racing Professional Sporting Activity; Games, Races, Contests of a professional nature Pyrotechnics /Explosives Rap or Heavy Metal Concerts Raves Rock Climbing, Climbing Wall Rodeo/Roping Events (includes practice) Scuba Diving Tractor/Truck Pulls Zip Line /Zip Lining SPECIAL EVENT LIABILITY GROUP INSURANCE TRUST DATE CERTIFICATE OF INSURANCE ENDORSEMENT 5/12/2025 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. THIS CERTIFICATE OF INSURANCE ENDORSEMENT DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. PRODUCER: SPECIAL EVENT INSURANCE DEPARTMENT CONTACT INFORMATION: HUB International Insurance Services Inc. PHONE 9256096547 FAX 9256096550 3000 Executive Parkway,Suite 300 EMAIL specialevent(a)hubinternational.com San Ramon,CA 94583 INSURER(S)AFFORDING COVERAGE NAIC# CA License#0757776 INSURER A: Colony Insurance Company 39993 NAMED INSURED: Santa Ana Public Library,City of Santa Ana 20 Civic.Ctr Plaza Santa Ana,CA 92701 COVERAGES This is to certify that the policies of insurance listed below have been issued to the insured named above for the event date(s)indicated below. Notwithstanding any requirement,term o 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. INSURED MEMBER INSR COVERAGE EFFECTIVE TYPE OF INSURANCE ENDORSEMENT / LIMITS LTR NUMBER EXPIRATION DATE A GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY 51086 05/23/2025 DAMAGE TO RENTED PREMISES $1,000,000 (Ea occurrence) CLAIMS-MADE Fx] OCCURRENCE MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OP AGG $2,000,000 LIQUOR LIABILITY PER OCCURRENCE(AGGREGATE INCLUDED IN GENERAL LIABILITY n/a AGGREGATE) MASTER POLICY#103 GL 0021111 -EFFECTIVE DATE 1/1/2025; EXPIRATION 1/1/2026 DESCRIPTION OF OPERATIONS/LOCATIONS City of Santa Ana,its officers,officials,employees and volunteers,20 Civic Center Plaza,Santa Ana,CA 92701 is/are included as an additional insured(s)per attached endorsement T5409-0118.Policy is Primary and Non-contributing per attached endorsement T1095-0108;Waiver of Subrogation applies per attached endorsement CG 24 04 05 09. Event Type: Vendor(1) Event clate(s): 5/23/2025 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana Attention: Ella Sepulveda AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza M-75 Santa Ana,CA 92701. POLICY#103 GL 0021111 COMMERCIAL GENERAL LIABILITY T5409-0118 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Named of Additional Insured Person(s)or Organization(s) City of Santa Ana,its officers,officials,employees and volunteers,20 Civic Center Plaza,Santa Ana,CA 92701 Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Section II-Who Is An Insured is amended to include as additional insured the person(s) or organization(s) shown in the Schedule, 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 omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations;or B. In connection with your premises owned by or rented to you. T5409-0118 ©ISO Properties,Inc.,2004 Page 1 of I POLICY#103 GL 0021111 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (Third-Party) This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, and all subparts thereof, as contained in the policy is deleted in its entirety and replaced with the following condition as respects the Third Party shown below: 4. Other Insurance a. With respect to the Third Party shown below, the insurance provided by this policy shall be primary and non-contributing insurance. Any and all other valid and collectible insurance available to such Third Party in respect of operations performed by you under written contractual agreements with said Third party for a loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. Third Party to whom this endorsement applies is: City of Santa Ana,its officers,officials,employees and volunteers,20 Civic Center Plaza,Santa Ana,CA 92701 Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing operations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. T1095-0108 Includes Copyrighted material of ISO Properties,Inc.with its permission. Page 1 of 1 POLICY#103 GL 0021111 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization to whom or to which you are obligated by virtue of a written contract to waive your right of recovery. The following is added to Paragraph 8.Transfer of Rights of Recovery Against Others to Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your world' done under a contact with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 24 04 05 09 Contains material copyright,Insurance Services Office,Inc.,with its permission. Page I of I MERCURY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE INSURANCE- Mercury Insurance Company P.O. BOX 10730,SANTA ANA,CA 92711-0730 " 4 AGENCY_AMERICAN CENTER INS(714)893-1881 F POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE CAAP0000787581 11/30/2024 05/3012025 YEAR MAKE VIN 2012 TOYOTA 5YFBU4EE7CP003058 NAMED INSURED ANN CHAU ADDITIONAL DRIVERS DON LAI TO REPORT A CLAIM, please call (800) 503-3724 For access to ROADSIDE ASSISTANCE ONLY, please call(866) 519-6478 This policy complies with§16056 or§16500.5 of the CA Vehicle Code. NAIC#27553 *< �k y ,�� �yz,�t S.' 14S Y-Y� ♦ t l f �/� ��A� j. 'C b�1�^'r � Yfanxt S s}{a�✓11 .� i Renewal Term Annual Mileage: 5,294 I Current Term Mileage Program: RealDrive-Verified o Renewal Term Mileage Program: RealDrive-Verified c Coverages Umits _ ..............................._......_... Preml Bodily InJury Uability ............_......................._........_...... Acc ..nt ......_.. $250,000 each Person/$500,000 each Accident 27g 00 5 Property Damage Liability $25um 0,000 each Accident $......._.................................................................. Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $33.00 Injury - Uninsured Motorist Property Collision Deductible Waiver Applies $2.00 Damage/Collision Deductible Waiver ....................ns-i_........._.........---................................................_...._------------................................................................ Comr ....................._...._............_ p e.....a Actual Cash Value Less$250 Deductible $34.00 ..olli....................._.-.....----............................................_......................._...............---..................................._.__. Collision ...........__...._...._...._.............. .. .......-... Actual Cash Value Less$500 ............................'----......._............In.......ed Total ......................T......R.... $1,000 Included Total Premium for 2015 TOYOTA PRIUS HGHBK 4DR $517.00 2012 TOYOTA COROLLA/S/LE SED 4DR,VIN:SYFBU4EE7CP003058 Garaging Address: 4759 Lakewood.Blvd,Lakewood,CA,90712-3512 Primary Use of the Vehicle: Commuting Current Term Annual Mileage: 338 Renewal Term Annual Mileage: 1,528 Current Term Mileage Program: ReaiDrive-Verified Renewal Term Mileage Program: Rea lDrive-Verified Coverages Umits Premium ----------.....-------'--................_.__.............._........................................................................................................................................._................ Bodily Injury Liability $250,000 each Person/$500,000 each Accident $289.00 Property Damage Liability $250,000 each Accident .........................................._........................_..................._.............................................................................................................._......................... Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $35.00 Injury-----.........._.... ................................................................................................................. ........................................................ Uninsured Motorist Property $3,500 each Accident $7.00 Damage/Collision Deductible Waiver ....--" ............_--- .------ ............................................................................................... ......._. ... Com rehensive .Actual Cash Value Less$250 Deductible $11.00 Non-Factory Equipment..._......................................._$1,000............................................._. Included Total Premium for 2012 TOYOTA COROLLA/S/LE SED 4DR $342.00 Subtotal Policy Premium(AIL Vehicles) $a59.00 .............................................--..........................................................................................................................._......_....._._...._.._............._...--'---'-'--.............----....... Fraud Fee $1.76 Total 6 Month Policy Premium(All Vehicles) $860.76 Policy Contract and Endorsements Your insurance policy and any endorsement(s)contain a full explanation of your coverage.The policy contract is form U-10 MIC California Auto Policy(03/2023).The contract is modified by endorsement(s): U-900 Amendatory Endorsement-California. U476 CA 03/2023 Page 2 of 2