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HomeMy WebLinkAboutPUTTING FOR EAGLE, LLC INSURANCE NOT ON FILE WORI; 11AY NOT PROCEED A-242fi-085-03 CITY CLERK DATE: JUN25MS o Piz CSR (0) FACILITY USE AGREEMENT WITH PUTTING FOR EAGLE FOR USE OF C L(Antl(01) RIVER VIEW GOLF COURSE THIS FACILITY USE AGREEMENT is made and entered into on June 16a', 2026,by and between Putting for Eagle LLC, a California limited liability company("User"), 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 ("City'). City and User may be collectively referred to as the"Parties" or individually as a "Party". RECITALS A. The User has a need for a venue to conduct golf instruction and/or lessons. B. The City acknowledges the community need for programs such as those offered by User that expand competitive, and non-competitive athletic opportunities within the City of Santa Ana. C. The Parties have entered into this Agreement for the purpose of setting forth the terms and conditions for the User to use designated areas at the River View Golf Course for the administration of golf instruction and/or lessons. The parties agree as follows: 1. GRANT OF PERMISSION AND FACILITIES TO BE USED City hereby grants User the limited,non-exclusive right to utilize designated areas of River View Golf Course ("Facilities") to provide golf instruction and/or lessons pursuant to the Scope of Use set forth in Exhibit A, attached hereto and incorporated herein by reference. 2. COMPENSATION For the use of the Facilities described in Section 1 of this Agreement, User shall pay City fees as described in Exhibit A. 3. TERM The term of this Agreement shall begin on July 1, 2026 and terminate on June 30, 2027, unless terminated pursuant to the terms of this Agreement. 4. COMPLIANCE WITH RULES AND REGULATIONS User shall use and occupy the Facilities in a safe and careful manner and shall comply with all applicable local, state, and federal laws in its use of and activities in the Facilities, including as to the conduct of its employees, agents, clients,customers,guests, and others using the Facilities by reason of this Agreement.User shall also comply with all rules and regulations of City in effect during its use of the Facilities.Failure to abide by such laws,rules, or regulations,or any condition Page 1 of 5 of this:Agreement,may result in the immediate termination of this Agreement in the sole discretion of the City. 5. BACKGROUND CHECKS User shall ensure that all employees, subcontractors, and any volunteers are fingerprinted and background checked prior to conducting any work pursuant to this Agreement.Use shall not assign any employee, agent, subcontractor, volunteer or the User personally to provide services pursuant to this Agreement, if that employee, agent, subcontractor, volunteer, or the User personally are required to register as a sex offender under California Penal Code Section 290 et seq,have a conviction for any crime of moral turpitude,have a conviction for asexual based crime, have a conviction for a violent felony as defined in California Penal Code Section 667.5(c),-or has ` a conviction for a serious felony as defined in California Penal Code Section 11923(c). Disqualifying convictions include but are not limited to, violations of California Penal Code Sections 37, 128, 136,1 with Section 186.22, 187, 190-190.4 and-192(a),205,206,207-209.5,211, 212, 212.5, 213, 214, 215, 218-219, 220, 236.1(b) or 236.1(c), 243.4, 261, 261.5, 273.5, 262, 264.1,266, 266c,266h,266i,266j,267,269,272,273a,273ab,273d,285,286,288,288a,288.21 I 288.3,288.4,288.5,288.7,289, 290,311.1,311.2,311.3,311.4,311.10-' 311.11,314,347(a),368, 417(b), 451.(a),518 with 186.22, 647.6, 653f(c), 664 and 187, 667.5(c)3 18745, 18750, or 18755, 12022.53, 11418(b)(1)or(b)(2); Business and Professions Code Section 729.' 6. INDEMNIFICATION User agrees to and shall indemnify, protect, defend, and hold harmless City, its officers, agents, employees, consultants, special counsel, and representatives from-and against any and all claims, damages,judgments, attorney's fees, costs and expenses arising out of, involving, or in connection with the use of the Facilities or the acts or omissions of User, its officers, agents, employees, volunteers, guests, or invitees, whether or not such acts or omissions constitute permitted uses of'the Facilities. 7. INSURANCE Insurance requirements are attached hereto and incorporated herein as Exhibit B. 8. CONFLICT OF INTEREST CLAUSE User 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. FORCE MAJUERE In the event that the Facilities are rendered unavailable due to destruction,partial or total, acts of nature, work stoppages or other labor disturbances, civil commotion, war, or any other Page 2 of 5 k i action by governmental agencies, or for any reason beyond the control of City, City shall have the right to terminate this Agreement without penalty. 10. LICENSES AND PERMITS User represents and warrants that it, and any agents, independent contractors, subcontractors,vendors,or others acting on its behalf under or with respect to this Agreement,will at all times during the term of this Agreement have and maintain in force any and all licenses, permits, or approvals required by law for the conduct of User's activities under this Agreement. 11. DAMAGE TO FACILITIES User shall be liable for any damage to the Facilities caused by any act of negligence of User, its partners, agents, servants, contractors, representatives, guests, employees, invitees, or customers. City may, at its option, repair such damage, and,User.agrees to.reimburse City for the total cost of repair. 12. PROPERTY BELONGING TO USER City shall not be responsible for lost, stolen, or damages property belonging to TJser, its partners, agents, servants, contractors, representatives, guests, employees,invitees, or customers. 13. NOTICE Any notice, tender, demand, delivery, or other conununication pursuant to this Agreement shall be in writing and directed to the addresses below or such addresses as either party may later specify in writing.Notice is deemed effective on the date it is given if hand-delivered or received by facsimile that day. Notice given by US, mail shall be deemed to have been given three (3) business days after it is deposited in the U.S.mail,postage prepaid and addressed as follows: To City: City Cleric City of Santa Ana 20 Civic Center Plaza(M-30) P.O.Box 1988 Santa Arta, CA 92702-•1988 With copies to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza(M-23) P.O. Box 1988 Santa Ana, California 92702 i Page 3 of 5 To User, Putting for Eagle Attn: Shaun Abbott 3701 S Ocean Crst Santa Ana, CA 92704 )uttin gforea=Ie00 ch 7mail.com 14. EXCLUSIVITY AND AMENDNIENT This Agreement represents the complete and exclusive statement between the City and User regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the parties regarding the use of the Facilities. 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 User. 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 User or 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. 15. ASSIGNNIENT User 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. User shall not allow any other person or entity to use the Facilities without the prior written consent of City. 16. TERMINATION This Agreement may be terminated by the City upon thirty(30) days written notice. 17. NONDISCRIMINATION User shall not discriminate because of race,color,creed, religion,sex, marital status,sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability,as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. User affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 18. .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 Page 4 of 5 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. 19. AUTHORITY The person(s) executing this Agreement on behalf of the Parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said Parties and that by so executing this Agreement, the Parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREOF, the Parties hereto have executed this Agreement the date and year first above written. AT EST• CITY OF SANTA A sAn r. e if�rL�H�11 �a . Alvaro Nunez Cit C er/ City Manager APPRO D AS TO FORM: SONIA R. CARVALHO USER: City Attorney Shaun Abbott(May 28,2'026 15.39 17 P71 JonathanT. Martine By: Shaun Abbott Assistant City Attorn Title:Golf instructor RECOMMENDED FOR APPROVAL: 6Recation ott and Community Services Agency i I Page 5 of 5 ; B �I I 1 EXHIBIT A SCOPE OF SERVICES I i i i i i I I Scope of Services 1. DESCRIPTION OF USE Putting for Eagle ("User", "Putting for Eagle") is a limited liability company focused on developing and providing advanced golf performance training. PUTTING FOR EAGLE may conduct the following activities,at designated areas within permitted City of Santa Ana Facilities: a. Small Group Golf Lessons, Camps and Programs A structured golf program offering participants the opportunity to develop and refine golf skills through structured practices.Participants will receive coaching focused on technique,physical conditioning, and sportsmanship,while fostering personal growth,discipline,and goal-setting. b. Private Golf Lessons This program will provide private,performance-focused instruction for up,intended to support golfers in achieving higher levels of technical proficiency and competitive readiness through customized coaching. 2. FACILITIES User is permitted-to operate the programming outlined in this Agreement at the following City of Santa Ana Facilities ("Facilities"): f a. River'View Golf Course 1800 W. Santa Clara Ave. Santa Ana, CA 92706 User shall use the Facilities solely for the purposes outlined in this Agreement and for no other purpose without the City's prior written consent.User shall not access or use the Facilities unless a City-authorized representative or designee is present.Assigned days,times,and designated areas are subject to modification during the period of this Agreement if required for City programs, maintenance, special events, or other operational needs, as determined by the City or assigned designee in its sole discretion. User shall comply with all applicable federal, state, and local laws, regulations, codes, and ordinances.User shall further comply with all directives issued by City of Santa Ana personnel or assigned designee, and applicable golf rules as may be promulgated from time to time by the City or assigned designee. User hereby acknowledges receipt of and agrees to comply with all current golf rules. The City reserves the right to relocate, reschedule,or suspend User's use if the scheduled Facility becomes inoperable, unsafe, or otherwise unavailable due to maintenance, emergency conditions, or operational necessity, as determined by the City or assigned designee. a 3 3. TERMS OF USE For a period of one (1) year, commencing July 1, 2026 and terminating June 30, 2027 ("Term"), 'Putting for Eagle may conduct golf programming during dates, times, and locations assigned weekly by City's assigned designee managing day-to-day golf course operations. Beginning July 1,2026,User shall be provided with City-designated driving range stations at River View Golf Course during operating hours as assigned by City's assigned designee. Requests for space allocations shall be made to City's assigned designee prior to use.User shall be responsible for managing participant attendance and submit attendance reports to City's assigned designee monthly. The City and its' assigned designee reserve the right to require adjustments to the schedule, staffing, or facility use based on the anticipated attendance. User shall provide City's assigned designee with written notice 30 days in advance of all group lessons and golf camps. All participants, shall execute the City of Santa Ana class waiver prior to facility entry.Participants under the age of eighteen (18) must have the waiver executed by a parent or legal guardian. Executed waivers shall be collected by User, submitted to City's assigned designee, and remain valid and on file for the duration of the Term. User shall be responsible for managing participant and spectator conduct. Spectators, including parents and guardians, shall remain in designated viewing areas and shall not be permitted unless authorized by City's assigned designee. User shall not sell, distribute, or otherwise provide for compensation any food, beverages, 1 concessions, merchandise, or promotional items at the Facilities without prior written approval from the City's assigned designee. s This prohibition shall include,but not be limited to; sales conducted by User's employees, agents, representatives,volunteers,participants,parents, or affiliated organizations.User shall not permit any third party to conduct sales,fundraising, or commercial activity at the Facilities in connection with User's programming without prior written approval from the City's assigned designee. 4. PERSONNEL User shall provide qualified, certified golf coaches for all golf activities conducted at City of Santa Ana facilities. User shall be solely responsible for the supervision, conduct, and control of its employees, agents,representatives,volunteers, and participants at all times. ' User shall not permit any third party, independent contractor,.parent,or participant to provide golf instruction or conduct golf programming at the Facilities without prior written approval from the .City. User shall not sublicense,assign,or otherwise permit third parties to utilize the Facilities for aquatic programming under this Agreement without prior written approval by the City. User shall ensure that all employees,agents,and representatives who work with or are in proximity to minors have successfully completed background screening and any other required certifi.catioris in compliance with applicable federal,state, and local requirements.User represents and warrants f that such personnel are legally eligible and suitable to work with minors. User shall ensure that no User personnel engage in one-on-one supervision of a minor in looker rooms, restrooms, or other private areas at the Facilities. User shall maintain appropriate supervision of participants at all times in all areas of the Facility,including locker rooms, spectator areas, and pool deck spaces. User shall be responsible for any injuries, losses, or damages arising out of or related to golf programming activities except to the extent caused by sole negligence or willful misconduct of the City. City's assigned designee shall conduct facility opening and closing procedures, and maintain required maintenance levels and ensure compliance with applicable health and safety regulations. The City reserves the night to immediately suspend golf activities due to weather conditions, air duality concerns,mechanical failure, contamination events, or any other condition deemed iuisafe for continued use, as determined by the City in its sole discretion. i S. EQUIPMENT 1 User shall be solely responsible for providing and maintaining all golf lesson related equipment, including. Storage of User equipment at the Facilities may be requested in writing and shall be subject to prior written approval by the City's assigned designee. Approval, if granted, may be revoked at the City's discretion. Any equipment stored at City Facilities must be well-maintained and kept orderly. - I User may display program-related signage at the Facilities only with the City's assigned designee prior written approval. All proposed banners shall be either jointly produced in coordination with the City in accordance with the City's style guide standards or submitted by User for review and approval prior to installation. User shall be solely responsible for all costs associated with the design,production; and installation of approved banners or signage. Approved banners shall be limited to designated display areas as determined by the City's assigned designee and shall comply with all size, content, placement, and installation requirements established by the City's assigned designee.All banners and signage shall be installed and removed in a manner that does not damage City property.User shall be responsible for any damage resulting from the installation,display, or removal of such materials.The City's assigned designee reserves the right to require the removal of any banner or signage at any time,in its sole discretion. User shall promptly notify the City's assigned designee, of any building or facility issues, including damage,vandalism, or theft. I 6. PAYMENT � The User shall pay a base fee of Five Hundred Dollars ($500.00) per month for the use of the Facility,for a total annual base fee of Six Thousand Dollars ($6,000) during the Term,. The City shall issue invoices for all assessed fees on a monthlybasis(or other agreed billing cycle). Late payments may be subject to penalties or interest as permitted by law. 7. NO EXCLUSIVE RIGHTS Nothing in this Agreement shall be construed to grant User any exclusive rights to use the Facilities or any portion thereof, The City's assigned designee reserves the right to schedule, operate, and permit the use of the Facilities by other individuals, organizations, or programs at any time, including during the Term of this Ag:eerneat. User acknowledges that its use of the Facilities is non-exclusive and subordinate to City programs, maintenance activities, special events, or other operational needs, as determined by the City in its sole discretion. Nothing in this Agreement shall be iriterpreted to create any priority scheduling rights, continued use rights, or expectation of renewal beyond the Terre stated herein. i `{F i 1 I Ik f 1 I EXHIBIT B INSURANCE REQUIREMENTS I E 1 Insurance Requirements User shall procure and maintain for the duration of the agreement,the following insurance coverages: 1V INMIUM SCOPE AND LIMIT OF INSURANCE User shall maintain limits of insurance coverage in the following minimum amounts and shall be at least as broad as: • Commercial General Liability(COL); 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. • Sexual Abuse or Molestation Liability (SAME): If the CGL policy referenced above is not endorsed to include affirmative coverage for sexual abuse or molestation, User shall obtain and maintain a policy covering Sexual Abuse and].Molestation with a limit of no less than$1,000,000 per occurrence or claim, • Automobile Liability(AL):Insurance Services Office Form CA 00 01 covering Code I (any auto),with combined single limits of$1,000,000.In the event User does not maintain comnnercial automobile liability insurance, City will accept evidence of personal automobile insurance, provided that such policy is endorsed for business use and provides coverage with a minimum limit of$1,000,000.Required policy limits can be met with primary and umbrella/excess insurance policies. • Workers' Compensation(WC): 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 User has no employees. User attests that its workers' compensation coverage extends to all persons who will be working with the City under the agreed scope of services. I£User 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 User. 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: I 1. CGL, SAML and AL policies: City of Santa Ana, its City Council,its officers, officials, I 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 User including materials,parts,equipment, and personnel furnished in connection with such work or operations. 2. COL,AL, and WC 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 User for City. E s i 3. All required insurance policies:For any claims related to this contract,User'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 User'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: Parks,Recreations,and Community Services Agency;20 Civic Center Plaza M- 23, Santa Ana,CA 92701.The name and the location of event should be included in the Description of Operations section of each certificate. Self-Insured Retentions Self-insured retentions roust be declared to and approved by the City.City may require User 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 AN, Best rating of no less than A:VII,unless otherwise acceptable to City. � Verification of Coverage User 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 User'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 torte with a retroactive,date prior to the contract effective date,User must purchase"extended reporting" coverage for.a minimum of three(3)years after completion of work. Subcontractors User shall require and verify that all sub-contractors maintain insurance meeting all the requirements stated herein, and User 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, i i f 0 ATE ACO CERTIFICATE OF LIABILITY INSURANCE D04/091206fYYYY) II�� 4I09/20Z6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Next First Insurance Agency,Inc. PHONE {855)222.5919 FAX PO BOX 60787 Arc Not: Palo AILG,CA 94306 E-MAIL p DORESS: support@nextinsurance.com A .P INSURERS AFFORDING COVERAGE NAIC# INSURER A: State National Insurance Company,Inc. 112831 INSURED INSURER 8 Shaun Abbott Putting for Eagle INSURER C 3701 S Ocean Crst Santa Ana,CA 92704 INSURER 0; INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:849998555 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUFD 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 BFFN REDUCED BY PAID CLAIMS. INPOLICY EFF POLICY EXP TRR TYPE OF INSURANCE A66L SUBR POLICY NUMBER MMIDDIYYYY) (MMIODfYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000.00 CLAIMS-MADE �OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $1 OD,OOD.00 MED EXP(Any one person) $5,000.0D A X NXTEPC09BU-06-GL 09/01/2025 09/01/2026 PERSONAL&ADV I NJURY $1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000.00 POLICY JECTPRO LOC PRODUCTS-COMPIOPAGG $3,000,000.00 X PRO- OTHER! $ AUTOMOBILE LIABILITY COMBINE D SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY{Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY{Per accident) HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETORIPARTNEPJEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? NIA - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 3 If yes,describe under DESCRIPTION OF OPERATIONS below E_L.DISEASE-POLICY LIMIT S Each Occurrence: $1,000,000.00 A Professional Liability NXTEPC09BU-06-GL 09/01/2025 09/01/2026 Aggregate: $3,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) The Certificate Holder is City Of Santa Ana.This Certificate Holder is an Additional Insured on the General Liability policy per the Additional Insured Automatic Status Endorsement,All Additional Insured privileges apply only if required by written agreement between the Certificate Holder and the insured,and are subject to policy terms and conditions. VAPPROVEDCERTIFICATE HOLDER CANCELLATIONu Tran Nguyen of 2:39 pm,Apr 13,202E City Of Santa Ana LIVE CERTIFICATE Attention:Parks,Recreation,and Community Services r- ® SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Agency THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Civic Center Plz#M-23 ' ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana,CA 92701 AUTHORIZED REPRESENTATIVE EBRO I Click Or Scan t0 View O 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Renewal Auto Policy Declarations MERCURY To report a claim please call (800) 503-3724 INSURANCE Policy Period Policy Number From: 11/06/2025 12:01 AM CAAP0000681334 To: 05/06/2026 12:01 AM Standard time at the address of the Named Insured Agent Company INSZONE INSURANCE.SERVICES(048983) Mercury Insurance Company 2721 CITRUS RD P.O.BOX 10730 STE A SANTA ANA,CA 92711-0730 RNCHO CORDOVA,CA 957426313 (877)308-9663 Named Insured SHAUN ABBOTT 3701 S OCEAN CRST SANTA ANA,CA 92704-7127 (714)310-0000 sabbott2222@gmail.com Important Information Date Sent: 10/07/2025 The enclosed Auto Insurance Renewal Bill and the U-251 IMPORTANT NOTICE are part of this policy, These specify the amount of your premium,your payment options, any applicable fees, and the due date.Your automobile insurance expires and coverage ceases at 12:01 AM on 11/06/2025. Coverage under this policy will become effective provided you pay the premium and any applicable fees as indicated on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent at the phone number provided above. This Declaration provides only a summary of coverage. All coverage is subject to the terms, conditions, and exclusions of the policy contract. Discounts 2020 CHEVROLET EQUINOX LT#94827-Exceptional Driver, Good Driver,Group Discount,Multi-Car 2025 HYUNDAI IONIQ 6 SEL#92314-Exceptional Driver,Good Driver,Group Discount, Multi-Car Listed Drivers SHAUN ABBOTT-Years License Experience:31 PAMELA N SCHEIDT-Years License Experience.45 Excluded Drivers None The Designated Excluded Drivers—Coverage Exclusion is applicable to all coverages, including but not limited to,liability and uninsured motorists, provided now or later. It is agreed that the insurance afforded by this policy shall not apply nor accrue to the benefit of any insured or any third-party claimant when any motor vehicle is being used or operated by an Excluded Driver designated above, regardless of where the person resides or whether the person is licensed to drive. Please refer to the terms of your auto policy. Additional Household Members None Vehicles and Coverage Limits 2020 CHEVROLET EQUINOX LT UTL 4DR,VIN:3GNAXKEVILL194827 Garaging Address: 3701 S Ocean Crst,Santa Ana,CA,92704-7127 U-176 CA 03/2023 Page 1 of 3 Primary Use of the Vehicle: Commuting Current Term Annual Mileage: 12,000 Renewal Term Annual Mileage: 12,000 Current Term Mileage Program: Estimated Renewal Term Mileage Program: Estimated Loss Payee/Additional interest LBS FINANCIAL CREDIT UNION, PO BOX 790062,5AN ANTONIO,TX,78279 Coverages Limits Premium ...................................................................................................................................................................................................................................... Bodily Injury Liability $100,000 each Person/$300,000 each Accident $378.00 Property Damage Liability $50,000 each Accident ..................................................................................................................................................................................................................................... Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $43.00 Injury ..................................................................................................................................................................................................................................... Uninsured Motorist Property Collision Deductible Waiver Applies $4.00 Damage/Collision Deductible Waiver ..............................................................••--.................................................................................................---.......................................-....................... Medical Payments $5,000 each Person/each Accident $14.00 . ................................................................................................................................................................................ Comprehensive Actual Cash Value Less$1,000 Deductible $49.00 ...... . . .......................................................................... .................................I............... Collision Actual Cash Value Less$1,000 Deductible $259.00 ..................................................................................................................................................................................................................................... Rental $40 each Day/Maximum 30 Days $27.00 ..................................................................................... . ...................................... Roadside Assistance $75 Towing and$75 for Non-Towing Services $4.00 per Occurrence/Maximum 3 Occurrences ..................................................................................................................................................................................................................................... Non-Factory Equipment $1,000 Included ----•...................................................................................................................................................................................................................... Total Premium for 2020 CHEVROLET EQUINOX LT UTL 4DR $778.00 2025 HYUNDAI IONIQ 6 SEL SED 4DR,VIN: KMHM34AA8SA092314 Garaging Address: 3701 S Ocean Crst,Santa Ana,CA,92704-7127 Primary Use of the Vehicle: Commuting Current Term Annual Mileage: 11,401 Renewal Term Annual Mileage: 11,401 Current Term Mileage Program: Estimated Renewal Term Mileage Program: Estimated Loss Payee/Additional Interest Hyundai Motor Finance, PO Box 20809,Fountain Valley,CA,92728 Coverages Limits Premium ...... i:l........................................... ........•-•-----•----..........................................----- •.................................-•--------.........-............................................. Bodily Injury Liability $100,000 each Person/$300,000 each Accident $380.00 Property Damage Liability $50,000 each Accident ............I.-................................................................................................................................................................................................................... Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $56.00 Injury ..............•----------.-•----...................................................................--................................................................................................................................ Uninsured Motorist Property Collision Deductible Waiver Applies $4.00 Damage/Collision Deductible Waiver ..................................................................................................................................................................................................................................... Medical Payments $5,000 each Person/each Accident $21.00 . ............................................................................................................................................................................................... Comprehensive Actual Cash Value Less$1,000 Deductible $116,00 ..................................................................................................................................................................................................................................... Collision Actual Cash Value Less$1,000 Deductible $431.00 ------•-•----•-•..................................................................................................................................................................................................................... Rental $40 each Day/Maximum 30 Days $27.00 ......................................................................•--•............................................................................................................................."I........................... Roadside Assistance $75 Towing and $75 for Nan-Towing Services $4.00 per Occurrence/Maximum 3 Occurrences ................................................................................................................................ ..................................................................................................... Nan-Factory Equipment $1,000 Included ...-................................................................................................................................................................................................................................. Total Premium for 2025 HYUNDAI IONIQ 6 SEL SED 4DR $1,039.00 Subtotal Policy Premium(All Vehicles) $1,817.00 ... ......... -.......................................................---••---.....-----------.................................--------•-•---------•................................-•--•--------...........................-....-....-----........... . ..... Fra.. ud Fe ee $1.76.... Total 6 Month Policy Premium(All Vehicles) $1,818.76 U-176 CA 03/2023 Page 2 of 3 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. U-176 CA 03/2023 Page 3 of 3 SCHEDULE OF POLICY CHANGES It is understood and agreed that: The following forms are added: CG 24 04 05 09-Waiver Of Transfer Of Rights Of Recovery Against Others To Us All other terms and conditions remain unchanged. IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 ❑ Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: NXTEPC09BU-06-GL COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization against whom you have agreed to waive such right of recovery in a written contract or agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 work" done under a contract 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. CG 24 04 05 09 ©Insurance Services Office, Inc., 2008 Page 1 of 1 13 SCHEDULE OF POLICY CHANGES It is understood and agreed that: The fallowing forms are added: CC 24 04 05 09-Waiver Of Transfer Of Rights Of Recovery Against Others To Us All other terms and conditions remain unchanged. IL 12 0111 85 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: NXTEPC09BU-06-GL COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization against whom you have agreed to waive such right of recovery in a written contract or agreement Information required to com lete this Schedule, if not shown above,will be shown in the Declarations. 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 work" done under a contract 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. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 'I of 1 ❑ COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II -WHO IS AN INSURED is amended to include the following as insureds: 1. Lessor of Leased Equipment Any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an insured only with respect to their 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 or organization. No such person or organization is an insured under this section: a. Upon expiration or termination of their contract or agreement with you for such leased equipment ends; b. For any"bodily injury"or"property damage"caused by an"occurrence"which takes place after expiration or termination of their contract or agreement with you; or c. For any "personal and advertising injury" caused by an "offense" which takes place after expiration or termination of their contract or agreement with you, 2. Managers or Lessors of Premises Any person or organization from whom you lease premises when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an insured only with respect to liability arising out of your ownership, maintenance or use of that part of the premises leased to you. No such person or organization is an insured under this section for any: a. For"bodily injury"or"property damage"caused by an"occurrence"which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. 3. Grantor of Franchise Any person or organization (referred to below as grantor of a franchise)with whom you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy,but only with respect to"bodily injury" or"property damage"arising out of" liability as grantor of a franchise to you R. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III LIMITS OIL INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. NXT-0115 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 2 permission COMMERCIAL.GENERAL LIABILITY C. With respect to the provisions of this endorsement, the following is added to SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4.Other Insurance: Regardless of whether other insurance is available to an additional insured on a primary basis, this insurance will be primary and noncontributory if a written contract between you and the additional insured specifically requires that this insurance be primary. All other terms and conditions of the policy remain unchanged. NXT-0115 BM GL 0218 Includes material copyrighted by Insurance Services office, Inc. used with its Page 2 of 2 permission COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ABUSE AN®.MOL,ESTATION COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Abuse or Molestation Limit of Insurance-Each Person:$100,000.00 Abuse or Molestation Limit of Insurance-Aggregate: $10e,00o.o0 The following changes apply only to the coverage provided by this endorsement. A. The following exclusion is added to Paragraph 2. Exclusions under SECTION I—COVERAGES, COVERAGE A—BODILY INJURY AND PROPERTY DAMAGE LIABILITY and COVERAGE B— PERSONAL AND ADVERTISING INJURY LIABILITY: This insurance does not apply to; Abuse Or Molestation "Bodily injury", "property damage"or"personal and advertising injury" arising out of the actual or threatened abuse, molestation or exploitation by anyone. This exclusion applies even if the claim against the insured alleges negligence or other wrongdoing in the employment, investigation, supervision, reporting to the proper authorities or failure to so report, training or retention. B. The following is added to SECTION I—COVERAGES: ABUSE OR MOLESTATION COVERAGE 1. Insuring Agreement a. We will pay those sums the insured becomes legally obligated to pay as damages because of"bodily injury' arising out of abuse, molestation or exploitation to which this insurance applies.We will have the right and duty to defend the insured against any"suit" seeking such damages. However, we will have no duty to defend the insured against any"suit" seeking damages to which this insurance does not apply. Nor do we have a duty to defend any insured who is alleged to have taken part in the abuse, molestation or exploitation. We may, at our discretion, investigate and settle any claim or"suit"that may result, But: (1) The amount we will pay for damages is limited as described in Paragraph C. Limits Of Insurance below; and (2) Our right and duty to defend ends when we have used up the applicable limit of insurance in the payment of judgments or settlements under Abuse Or Molestation Coverage. b. This insurance applies to"bodily injury" arising out of abuse, molestation or exploitation only if the abuse, molestation or exploitation: (1) Takes place in the"coverage territory"; (2) Results from the insured's negligence in employment, investigation, supervision, reporting to the proper authorities or failure to so report, training or retention;and (3) First occurs during the policy period. NXT-0114 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 3 permission Nguyen, Tu Tran From: Chandler, Brandon Sent: Monday, April 13, 2026 1:30 PM To: RM D Cc: Nguyen, Tu Tran Subject: RE: Request for COI Review: Putting for Eagle LLC This is approved to waive based on the scope of service. Thank you. Brandon Chandler I Risk Manager City of Santa Ana - Human Resources Department 20 Civic Center Plaza Santa Ana, CA 92701 Office: 714-647-5472 Work Motile: 714-451-6620 Email: bchandlerAsanta-ana.org I santa-ana.org/human-resources Linkedln [ Instagram City Hall hours are 8 a.m.to 5 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. every other Friday. Click here for a list of observed holidays and Friday closure dates. The mySantaAna mobile app puts the power of the Santa Ana city government in the palm of your hand! The free app allows residents to quickly and easily report issues to the City, access City services, and find news and events. It is available to download from the Apple App Store and on Google Play. Click here to report an issue directly from the City website. From: RMD <rmd@santa-ana.org> Sent: Monday, April 13, 2026 12:41 PM To: Chandler, Brandon <bchandler@santa-ana.org> Subject: FW: Request for COI Review: Putting for Eagle LLC Hi Brandon,. Parks and Recreation is requesting to waive the $1 M policy limit and business use endorsement for the Personal Auto Requirement for this agreement. This agreement is a facility use agreement for independent golf instructors to operate and run lessons at the River View Golf Course. Please advise. Kind regards, COMMERCIAL GENERAL LIABILITY c. Abuse, molestation or exploitation which first occurs during the policy period includes any continuation, change or resumption of that abuse, molestation or exploitation after the end of the policyperiod. d. Multiple acts of abuse, molestation or exploitation of any one person by one or more perpetrators will be deemed to have first occurred at the time of the first act of such abuse, molestation or exploitation and shall be subject to the coverage and limits in effect at the time of the first act of abuse, molestation orexploitation. 2. Exclusions This insurance does not apply to: a. Fines And Penalties Any fines, penalties, punitive damages, exemplary damages or aggravated damages. b. Participating Insured Any insured who takes part in the abuse, molestation or exploitation. c. Passive Insured Any insured who remains passive upon gaining knowledge of any actual, alleged or threatened abuse, molestation or exploitation. G. SECTION III—LIMITS OF INSURANCE is replaced by thefollowing: SECTION III--LIMITS OF INSURANCE 1. The Limits of Insurance shown in the SCHEDULE above and the rules below fix the most we will pay under Abuse Or Molestation Coverage regardless of the number of: a. Insureds; b. Claims made or"suits" brought;or c. Persons or organizations making claims or bringing"suits". 2. The Aggregate limit shown in the Schedule of this endorsement is the most we will pay under Abuse Or Molestation Coverage for the sum of all damages. 3. Subject to Paragraph 2. above, the Each Person limit shown in the Schedule of this endorsement is the most we will pay under Abuse Or Molestation Coverage for damages because of"bodily injury" arising out of abuse, molestation or exploitation committed upon any one person, regardless of the number of acts of abuse, molestation or exploitation committed, the period of time over which such acts occur, or the number of perpetrators taking part in the abuse, molestation or exploitation. 4. The coverage provided by this endorsement does not provide any duplication or overlap of any other coverage provided elsewhere in this policy. No coverage is provided for abuse, molestation or exploitation under this policy except as provided in this endorsement. 5. The Limits of Insurance provided by this endorsement are in addition to, not part of, the Limits of Insurance provided by the Commercial General Liability Coverage Form. The Limits of Insurance shown in the Schedule of this endorsement apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations of the Commercial General Liability Coverage Form, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. NXT-0114 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 2 of 3 permission COMMERCIAL GENERAL LIABILITY D. SECTION IV—COMMERCIAL GENERAL,LIABILITY CONDITIONS is amended as follows: The heading and Paragraph a. of Condition 2. is replaced by thefollowing: 2. Duties In The Event Of Abuse, Molestation, Exploitation, Claim OrSult a. You must see to it that we are notified as soon as practicable of an act or allegation of abuse, molestation or exploitation which may result in a claim.To the extent possible, notice should include: (1) How, when and where the abuse, molestation or exploitation took place; (2) The names and addresses of any injured persons and witnesses;and (3) The nature and location of any injury or damage arising out of the abuse, molestation or exploitation. 2. The following is added to Paragraph b. Excess Insurance of Condition 4.Otherinsurance: The insurance provided by this endorsement is excess over any other insurance provided to any insured, whether such other insurance is provided on a primary, excess, contingent or any other basis, unless such other insurance is written to be specifically excess of this insurance. 3. The following Condition is added: Multiple Coverage Forms Or Policies Issued By Us When two or more Coverage Forms or policies issued by us apply to the same claim, "suit" or loss, the maximum limit of our liability under all such Coverage Forms or policies combined shall not exceed the highest applicable limit of liability under any one Coverage Form or policy among them. E. Definition 3. "bodily injury" under SECTION V—DEFINITIONS is amended asfollows: "Bodily injury" means bodily injury, sickness, disease, mental anguish or emotional distress sustained by a person, including death resulting from any of these at any time. All other terms and conditions of the policy remain unchanged. NXT-0114 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc.used with its Page 3 of 3 permission Tu Tran Nguyen I Risk Management Technician City of Santa Ana - Human Resources Department 20 Civic Center Plaza I Santa Ana, CA 92701 Office: 714-647-5141 Email: TNguyen20@santa-ana.org I santa-ana.orq/human-resources I Linkedln � Insta.gram City Hall hours are 8 a.m. to 5 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. every other Friday. Click here for a list of observed holidays and Friday closure dates. The mySantaAna mobile app puts the power of the Santa Ana city government in the palm of your hand! The free app allows residents to quickly and easily report issues to the City, access City services, and find news and events. It is available to download from the Apple App Store and on Google Play. Click here to report an issue directly from the City website. From: Uribe,Juan <iuribe@santa-ana.org> Sent: Monday,April 13, 2026 8:30 AM To: RMD<rmd@santa-ana,org> Cc: Lantz, Corilyn <clantz@santa-ana.org> Subject: Request for COI Review: Putting for Eagle LLC Good morning, PRCSA would like to request review of the attached insurance documents for Putting for Eagle LLC for golf instruction at the River View Golf Course. Included in this email are the CGL w/endorsements,Workers' Camp exemption farm, personal automobile policy to be used, and the email with RMD regarding the insurance requirements for facility rental permits. Request Type (check only one): M Standard C01 Review—Risk Management will review and approve insurance documents submitted. This applies to PO, Event, R Permit, and Agreements. ❑ Renewal COI Review— Risk Management will review and approve renewal insurance documents submitted. This applies to PO, Reservations, Permit, and Agreements. Please attach insurance requirements and previously approved COI(s). ❑ Request Insurance Requirements - Risk Management will provide insurance requirements for agreements and RFPs. C]Review Agreement/RFP Language- Risk Management will review Insurance, Indemnification/Hold Harmless, Limitation of Liabil of agreements and RFPs. All fields required to advance the process—do not delete or modify. City Contact Department: PRCSA Project Manager Name: Corilyn Lantz Project Manager Email: clantz@santa-ana.org. Contract Details: Business Name: Putting for Eagle LLC 2 Agreement Number and Agreement N/A Link: Facility rental permit for Instructor to provide Brief description of services: golf lessons to participants at the River View Golf Course for all ages. Contractor/Insured Contact Contact Name Shaun Abbott Contact Email Address: Iputtingforeagle00@gmail.com Contact Phone: I'I 714-287-7091 Insurance Contact(may be found at top right of the ACORD form) Contact Name: N/A Contact Email Address: N/A Contact Phone: N/A Please inform us if there are any questions. Thank you, ' - - Juan Magana Uribe Management Aide (' City of Santa Ana, Parks, Recreation and Community Services t +' 20 Civic Center Plaza, Santa Ana, CA 92701 (714) 571-4276 1 luribe(cDsanta-ana.org "City Mall is closed every other Friday. Click here for dates" 3 CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVII'OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE i, tirtGivNr , �)b� r V,/otr ("Representative"),attest that I am an authorized {Nei,lc end 71ik of YnEdar Eicpre�c�nlative) mpresse'ntative of 41 "fi�v� � =G, L�-C_ ("Company"), (on5ullant,'Ccenpany Ntnne) p Y"):and C 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 ("Agreement")to provide 6!�a ff l e 550---5 ("Services'); (Services to be provided tinder agreemunttcanuact) During the course and scope of Company's agreement with the City of Santa Arta,Company will not employ any person in any manner so as to become subject to the workers'compensation laws of California,and agree that if Company should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,Company shall forthwith comply with the provisions and provide proof of workers'compensation coverage immediately. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional 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 f y and all damages. Swam llate Print Name - Title Contact Information,i.e..Telephone Number and/or Entail Atldrass WARM LNG: FAILURE TO SECI)RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS($100,000).IN ADDITION TO THE-COST OF COMPENSATION,DAMAG13S AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATFORNEY'S FEES. Affkfavlt of Exemption fur WudWV Competr¢atlon Insurance tt 12 2024 Renewal Auto Policy Declarations � MERCURY To report a claim please call (800) 503-3724 INSURANCE Policy Period Policy Number From: 05/06/2026 12:01 AM CAAP0000681334 To: 11/06/2026 12:01 AM APPROVED Standard time at the address of the Named Insured By Tu Tran Nguyen at 2.28 pm,Jun 25,2026 Agent Company INSZONE INSURANCE SERVICES(048983) Mercury Insurance Company 2721 CITRUS RD P.O. BOX 10730 STE A SANTA ANA,CA 92711-0730 RNCHO CORDOVA,CA 957426313 (877)308-9663 Named Insured SHAUN ABBOTT 3701 S OCEAN CRST SANTA ANA,CA 92704-7127 (714)310-0000 sabbott2222@gmail.com Important Information Date Sent:04/07/2026 The enclosed Auto Insurance Renewal Bill and the U-251 IMPORTANT NOTICE are part of this policy. These specify the amount of your premium,your payment options, any applicable fees, and the due date. Your automobile insurance expires and coverage ceases at 12:01 AM on 05/06/2026. Coverage under this policy will become effective provided you pay the premium and any applicable fees as indicated on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent at the phone number provided above. This Declaration provides only a summary of coverage. All coverage is subject to the terms, conditions, and exclusions of the policy contract. Discounts 2025 HYUNDAI IONIQ 6 SEL#92314- Exceptional Driver,Good Driver,Group Discount, Multi-Car 2024 HYUNDAI SANTA FE XRT#55481- Exceptional Driver,Good Driver,Group Discount, Multi-Car Listed Drivers SHAUN ABBOTT-Years License Experience:32 PAMELA N SCHEIDT-Years License Experience:45 Excluded Drivers None The Designated Excluded Drivers—Coverage Exclusion is applicable to all coverages,including but not limited to, liability and uninsured motorists, provided now or later. It is agreed that the insurance afforded by this policy shall not apply nor accrue to the benefit of any insured or any third-party claimant when any motor vehicle is being used or operated by an Excluded Driver designated above, regardless of where the person resides or whether the person is licensed to drive. Please refer to the terms of your auto policy. Additional Household Members None Vehicles and Coverage Limits 2025 HYUNDAI IONIQ 6 SEL SED 4DR,VIN: KMHM34AA8SA092314 Garaging Address: 3701 S Ocean Crst,Santa Ana,CA,92704-7127 U-176 CA 01/2025 Page 1 of 2 Primary Use of the Vehicle: Commuting Current Term Annual Mileage: 11,401 Renewal Term Annual Mileage: 11,401 Current Term Mileage Program: Estimated Renewal Term Mileage Program: Estimated Loss Payee/Additional Interest Hyundai Motor Finance, PO Box 20809,Fountain Valley,CA,92728 Coverages Limits Premium ............................................................................................................................................................................................................................................... Bodily Injury Liability $100,000 each Person/$300,000 each Accident $391.00 Property Damage Liability $50,000 each Accident .............................................................................................................................................................................................................................................. Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $56.00 Injury .............................................................................................................................................................................................................................................. Uninsured Motorist Property Collision Deductible Waiver Applies $4.00 Damage/Collision Deductible Waiver .............................................................................................................................................................................................................................................. Medical Payments $5,000 each Person/each Accident $21.00 .............................................................................................................................................................................................................................................. Comprehensive Actual Cash Value Less$1,000 Deductible $116.00 .............................................................................................................................................................................................................................................. Collision Actual Cash Value Less$1,000 Deductible $431.00 .............................................................................................................................................................................................................................................. Rental $40 each Day/Maximum 30 Days $27.00 .............................................................................................................................................................................................................................................. Roadside Assistance $75 Towing and$75 for Non-Towing Services $4.00 per Occurrence/Maximum 3 Occurrences .............................................................................................................................................................................................................................................. Non-Factory Equipment $1,000 Included .............................................................................................................................................................................................................................................. Total Premium for 2025 HYUNDAI IONIQ 6 SEL SED 4DR $1,050.00 2024 HYUNDAI SANTA FE XRT UTL 4X4 4D,VIN:5NMP3DGL4RH055481 Garaging Address: 3701 S Ocean Crst,Santa Ana,CA,92704-7127 Primary Use of the Vehicle: Commuting Current Term Annual Mileage: 9,000 Renewal Term Annual Mileage: 9,000 Current Term Mileage Program: Estimated Renewal Term Mileage Program: Estimated Coverages Limits Premium ............................................................................................................................................................................................................................................... Bodily Injury Liability $100,000 each Person/$300,000 each Accident $336.00 Property Damage Liability $50,000 each Accident .............................................................................................................................................................................................................................................. Uninsured/Underinsured Motorist Bodily $30,000 each Person/$60,000 each Accident $36.00 Injury .............................................................................................................................................................................................................................................. Uninsured Motorist Property Collision Deductible Waiver Applies $4.00 Damage/Collision Deductible Waiver .............................................................................................................................................................................................................................................. Medical Payments $5,000 each Person/each Accident $15.00 .............................................................................................................................................................................................................................................. Comprehensive Actual Cash Value Less$1,000 Deductible $39.00 .............................................................................................................................................................................................................................................. Collision Actual Cash Value Less$1,000 Deductible $279.00 .............................................................................................................................................................................................................................................. Rental $40 each Day/Maximum 30 Days $27.00 .............................................................................................................................................................................................................................................. Non-Factory Equipment $1,000 Included .............................................................................................................................................................................................................................................. Total Premium for 2024 HYUNDAI SANTA FE XRT UTL 4X4 4D $736.00 Subtotal Policy Premium(All Vehicles) $1,786.00 ............................................................................................................................................................................................................................................................................... Fraud Fee $1.76 ............................................................................................................................................................................................................................................................................... Consumer Group Intervenor Fee $0.06 ............................................................................................................................................................................................................................................................................... Total 6 Month Policy Premium(All Vehicles) $1,787.82 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. U-176 CA 01/2025 Page 2 of 2