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HomeMy WebLinkAboutRELAMPAGO DEL CIELO INC. INSURANCE NOT ON FILE N-2025-259 WORK MAY NOT PROCEED CITY CLERK DATE: OCT 16 2025 Sup,TMltl15 (per) M i - December 23,2024 Relampago del Cielo, Inc. ("Speaker/Performer") P.O. Box 3158 Santa Ana, CA 92703 Re: Speaker/Performer Engagement Agreement This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: I. Event Description:As further described in Exhibit A,attached hereto,in celebration of and to provide performances for varied City Events, 2. Date(s): See Exhibit A;Term of this Agreement is 2 years from date above. 3. Event Time(s): See Exhibit A 4. Location: See Exhibit A 5. Compensation: $10,000(payable by check within 30 calendar days of event) except for costs detailed in Exhibit B which shall be paid after full execution of this Agreement. Speaker/Performer must provide IRS form W-9 before payment can be made. 6. Provided by City:microphone,projector, event space, tables and chairs. 7. Provided by Speaker/Performer: all other equipment and materials necessary. 8. City Contact Person (for coordinating purposes only): Tina Lee(ext 5214) 9. Independent Contractor: Speaker/Perfonner 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 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. Insurance: Insurance shall be procured and maintained by the Speaker/Performer as required by the City and as further detailed in Exhibit C,attached hereto and incorporated herein. 11. Indemnification: Speaker/Perfonner,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. 12. 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 Speaker Agreement—Relampago del Cielo, Inc. Page 2 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. 13. 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 webcast or any other means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Perfonmer. Copies of Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such recordings. 14. Speaker/Perfonner is solely responsible for payment of royalty fees, performance fees, or similar fees that may be required by unions or similar organizations. Speaker/Performer 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. 15. 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. 16. 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. 17. This Agreement represents the complete and exclusive statement between the City and Speaker/Perfonner 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 AN SPEAKER/PERFORMER Alvaro Nunez Marlene Pena-Marin City Manager President and Director ATTEST: ; APPROVED AS TO FORM: � Bv: !!!000, ennifer . a onathan T.Martinez Ci C Assistant City Attorney EXHIBIT A SCOPE OF SERVICES VENDOR INFORMATION Relampago Del Cielo Inc Address: PO BOX 3158, Santa Ana, CA 92703 Email marlene a?rdcgf.org EVENTS: 2024 Mayor and Council Installation and other City events in 2025 &2026. LOCATIONS: - 2024 Mayor and Council Installation: Bowers Museum, 2002 N. Main Street, Santa Ana, CA 92706. - Other events: to be determined, in writing, by the Parties. TERM: Two years from date on Speaker/Performer Agreement COMPENSATION: Not to exceed$10,000. Amount per service date will be coordinated, in writing,between vendor and city staff. City agrees to compensate Relampago del Cielo for services provided on December 10, 2024, as detailed in Invoice 923973, attached hereto as Exhibit B. DESCRIPTION: Vendor shall provide folklorico dance performances for the city-sponsored, community outreach events at the city's designated sites. Relampago Del Cielo Inc provided one of the performances for the 2024 Mayor and Council Installation at Bowers Museum, 2002 N. Main Street, Santa Ana, CA 92706 on Tuesday, December 10, 2024. The City will be responsible for setting up the space for the performances and promoting the events. Vendor will be responsible for providing materials, supplies and personnel necessary to provide the performance. City staff will be present at all time during the performance. Exhibit B Relampago Del Cielo Inc - r -0" L5 ' Invoice 23973 PO BOX 3158 i Santa Ana, CA 92703 US - �; �os.cr.orart t 1 7148814732 C1 accounting@rdcgf.org -- www.rdcgf.org BILL TO Tina Do Lee City of Santa Ana DATE DUE DATE 20 Civic Center Plaza 12f0412024 + + 12/04/2024 Santa Ana, CA 92701 DATE DESCRIPTION CITY RATE AMOUNT Performance Performance Fee - 10 min 1 700.00 700.00 performance on 12/10/24 @7:00 pm SUBTOTAL 700.00 TAX 0.00 TOTAL 700.00 TOTAL DUE $700.00 THANK YOU. Exhibit C Insurance Requirements Speaker/Performer shall procure and maintain for the duration of the agreement, the following insurance coverages: MINIMUM SCOPE AND LIMIT OF INSURANCE Speaker/Performer 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 $2,000,000 per occurrence and $4,000,000 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 Speaker/Performer 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. • Workers' Compensation (WIC): as required by the State of California, with statutory limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident, per employee, per policy for bodily injury or disease. This requirement can be waived if Vendor has no employees. If Speaker/Performer maintains broader coverage and/or higher limits than the minimums shown above, City requires and shall be entitled to the broader coverage andfor the higher limits maintained by Speaker/Performer. 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 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 nonpayment. Exhibit C Insurance Requirements 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 Speaker/Performer 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:VI I, 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 CGI, 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 Speaker/Performer shall require and verify that all sub-contractors maintain insurance meeting all the requirements stated herein,and Speaker/Performer 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. AC RO©��-- CERTIFICATE OF LIABILITY INSURANCE °A1210612©2�""' 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 INSUR ENS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poRcies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Gabriel Diaz(976132M) PHONE FAX 2706 Harbor Blvd Ste 201 (A/C,NO,ExT):714-434-7600 (A/C,NO): 714-434-6163 E-MAIL Costa Mesa CA 92626-5119 ADDRESS: gdiaz@farmersagent-corn INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Truck Insurance Exchange 21709 INSURER B: Farmers Insurance Exchange 21652 PO BOX 3158AGO DEL CIELQ, INC. INSURER c: Mid Century Insurance Company 21687 PO 60X 3158 INSURER D: SANTA ANA CA 92703 ENSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS iS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUFDTO THE INSURED NAME ABOVE FORTHE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPEOFINSURANCE ADDTL SUER POLICYNUMBER P4/ LTA CYEFF POLICYEXP LIMITS INSD WVD (MMDD/YYYY) (MM/DD/YYYY) COMMERCIAL GEN ERAL LIABILITY EACHOCCURRENCE $ 2,000,000 $ CLAIMS-MADE OCCUR DAMAGETORENTED PREMISES(Ea Occurmnce) 75,Q00 M ED EXP(Any one person) $ 5,000 A Y Y 604334609 03/07/2024 03/07/2025 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAI.AGGREGATE $ 4,000,00 POLICY n PROJECT ❑ LCC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOSILELIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 2,000.00 ANY AUTO BODILY INJURY(Per person) $ OWN � AIJ O EDAUTOS SCHEDULED BODILY INJURY(Par accident)$ Y Y 604334509 03107/2024 03/07/2025 HIRED AUTOS X NON-OWNED ONLY AUTOSONLY PROPERTY DAMAGE .$ (Per accident) UMBRELLAUAB OCCUR EACH OCCURRENCE $ EXCESS HAD CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE OTHER ANY PROPRIETUR/PARTNER/ Y/N E.L.EACH ACCIDENT $ EXECUTIVE OFFICER/MEMBER N/A EXCLUDED?(Mandatory in NH) E.L.DISEASE-FA EMPLOYEE if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCYLIMIT $ VESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 191,Additional Remarks Schedule,may be attached if more space is required) 00 W SANTA ANA BLVD,SANTA ANA,CA 92701;City of Santa Ana,its City Council,its officers,officials,employees,agents,and volunteers are to be covered s additional insureds with respect to liability arising out of work or operations performed by or on behalf of the instructor including materials,parts,equipment, and personnel furnished in connection with such work or operations. nigitAlysigned TLl Tran by Tu Tran lguyen"9°ye" APPROVED i L:os:i o-oT oo B Tu Tran Nguyen en at 11':04 am,Oct 07,2025 CERTIFICATE HOLDER CANCELLATION Y 9 Y City of Santa Ana, ATTN:Library Agency SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CIO Patty Lopez DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Drive M-42 AUTHO Gabriel A.Diaz SANTA ANA CA 92701 ACORD 25(2016/03) 01 9 88-201 5 ACORD �TION.All�RightR�..,,v�,d 31-1769 1 1-15 The ACORD name and logo are registered marks of ACORD {� DATE(MMlDDlYYYY) ' �►�oRa CERTIFICATE OF LIABILITY INSURANCE osro4r2a25 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Aidee Lopez PRODUCER E. State Farm Aidee Lopez Insurance Agency Inc PAIL Ho Ext: 714-775-3090 HO AIc No: 1415 S Broadway St E M RIE Santa Ana CA 92707 INSURERIS)AFFORDING COVERAGE NAIC it INSURER A: State Farm Fire and Casualty Company 25143 INSURED INSURER B: El Reiampago De Cielo, Inc INSURER C: PO Box 3158 INSURER D: Santa Ana CA 92703 INSURER E: LEI INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. P ADD SUB OLICY EFT POLICY E P ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ CLAIMS-MADE1-1 OCCUR PREMISES Ea occurrence MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRO- PRODUCTS-COMPIOPAGG S POLICY JECT LOC 5 OTHER: AUTOMOBILE LIABILITY (Ea acccideD LIMIT ISINGLE S ANY AUTO BODILY INJURY(Per person) S OWNED F SCHEDULED BODILY INJURY(Per accident) s AUTOS ONLY AUTOS HIRED k NON-OWNED AUTOS ONLY AUTOS ONLY Per accident $ 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION 5 WORKERS COMPENSATION PER OTH- $ AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT S 1,000,000 X OFFICERIMEMBER EXCLUDED? N r A 92-TA-J873 6 09115/2024 09115/2025 EL.DISEASE-EA EMPLOYE S 1,000,000 ;Mandatory in NHI t yes,describe under E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 600 W SANTA ANA BLVD,SANTA ANA,CA 92701: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 instructor including materials,parts, equipment,and personnel furnished in connection with such work or operations.Waiver of Subrogation applies. Location:Centennial Park-City of Santa Ana, 3000 W Edinger Ave.,Santa Ana,CA 92704,Concert In The Park. APPROVED By Tu Tran Nguyen at 7:23 am,Jul 02,2025 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana,Attention:Executive Director,Community ACCORDANCE WITH THE POLICY PROVISIONS. Development Agency,20 Civic Center Plaza M-25,Santa Ana, AUTHORIZED REPRESENTATIVE CA 92701 Completed by an authorized State Farm representative. If signature is required,please contact a State Farm agent. O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 732649.14 00.-13-2022 POLICY NUMBER, 60433-45-09 BUSII ESSO'UVNERS THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: f3USlNl SSOWA ERS POLICY SCHEDULE* Name Of Person Or Organization; GXTV OF SANT'A ANA AND XTS OFFICERS, AGENTS & EMPLOYEES Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. The following is added to Paragraph C..Who Is An Insured in the Businessownere Liability Coverage Form; 4. Any persona or organization shown In the Sched- We is also an 'Insured, but only with respect to !lability arising out of your ongoing operations or premises owned by or rented to you. IT IS FURTHER AGREED THAT THIS INSURANCE SHALL BE PRIMARY AND NON CONTRIBUTORY BUT ONLY ILA 'FETE EVENT Op INSURED'S SoLp, NEGLIGENCE. BP 04 48 0197 Copyright, Insurance Services C3fl m, Inc., 1997 page I of 1 0 POLICY NUMBER, 604BB-45-09 BUSINESSOWNERGS THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided underthe following. € USINE SOWi*IEPS POLICY SCHEDULV Name Of Person Or organization: ITV OV SANTA ANA AND ITS OFFICERS, AGENTS & EMPLOYEES " Information required: to complete this Schedule, if not shown on this endorsement, will be shown In the Declarations. The following is added to Paragraph 0. Who Is An Insurtd in the Dualnessowners Liability Coverage Farm: 4, Any person or organization shown in the Schad- ule is alao an'insured, but only with respoot to liability arising out of your ongoinn operatiori5 or poomises owned by or rented to you. IT IS i;'1:JR':C`HER :GREED THAT THIS INSURANCE SHALL BE PRIMARY AND NON CONTRIBUTORY BUT ONLY IN THE tVENT OF INSlr3!]. BD'S SOLV NEGLIGNNCE. 9 BP 04 48 01 97 Copyright, Insurance Services 6mce, Inc., 1907 Page 1 of 1 C l WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 M (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the.right to recover our payments from anyone liable for an injury covered by this policy. We.will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to.obtain this agreement from us..) You mu-st maintain payroll redords aac.urately segregating the remuneration of your employees whild engaged in the work-.described in the Schedule. The.additional premium for this endorsement shall be s. % of the California workers'.compensation premium otherwise due on.such remuneration. :'Schedule Person or Organization Jab Description CITY" OF SANTA ANA RISK CONTRACT. -$7,000 CODE. -8".1 MANAGMENT DIVISION CITY OF SANTA ANA CITY OIL SANTA ANA, ITS COUNCIL, OFFICERS, OFFICAL$,EMPLOYEES, AGENTS, AND VOLUNTEERS 20 CIVIC CENTER PLAZA SANTA ANA CA 92701-4058' This endorsement changes the polity to.which it is•ottachad and is offective on tho date issued unless otherwise statod. (The-information below is required only when this endorsement is i.ssued.subsequent to preparation of thepolicy.) Endorsement Effective 09/15/24 FolicyNo. 92-TA-0873-6 Endorsement No. Insured RELAMPAGO DEL CIELO, INC Insuran.ce Company State Farm Fjji e Land Casualty Company Countersigned By WC.04 0$OB. (Ed.4-84) 1007722 124!28�.2 0145-Miq CITY OF SANTA ANAAEN Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE I, r , d ("Representative"),attest that I am an authorized ame and Title of vendor Representative) representative of (7 ("Company"), and (C nsul t/Company Name) possess the authority to legally bind Company. In my capacity as Representative of Company,I represent and confirm the following,as relates to the agreement between Company and City of Santa Ana, agreement number N l ("Agreement")to provide_ 1 NeS Ir ti r i5� hya+- . "Services"): (SepUces to be provided tender agreementicontract) During the course and scope of Company's agreement with the City of Santa Ana, Company employees,consultants,representatives,and agents will not use and/or drive any Company owned/rented/leased/borrowed vehicles to perform Services to, for, or on behalf of City of Santa Ana. If at any time it is found that Company is not adhering to any andlor all of the statements in this document and does not maintain the minimum automobile liability insurance coverage as required in the Agreement,it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. l Signature 1 Date r Print N 1 � Title Contact Information,i.e.,"telephone Number and/or Email Address Affidavit of Exemption for Automobile Liability Insurance 11.12.2024