HomeMy WebLinkAboutGOODWILL INDUSTRIES OF O. C. - 2010 ON THE JOB TRAINING INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES N-2010-097
7-/-
CLERK OF COUNCIL
DATE:.
O ; Cr))A Cz7$EP 2 3 2010
12/09
Agreement No.
ON-THE-JOB TRAINING AGREEMENT
UNDER THE WORKFORCE INVESTMENT ACT
THIS AGREEMENT is made and entered into this 16th day of August, 2010 between the City of Santa
Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of
the State of California (hereinafter "CITY") and Goodwill Industries of Orange County (hereinafter
"EMPLOYER").
W I T N E S S E T H
Recitals:
A. CITY has been designated a Local Workforce Investment Area ("LWIA") pursuant to Section
116 of the Workforce Investment Act ("WIA"), P.L. 105-220, 29 USC Section 2801, to receive federal funds to
promote effective delivery of job training services to local area residents.
B. The State of California has created the California Workforce Investment Board pursuant to
Section 111 of the Workforce Investment Act, P. L. 105-220, 29 USC 2821 to administer the WIA programs
operated by the State of California.
C. As a LWIA, CITY is entitled to receive federal funds to establish programs to prepare eligible
unskilled youth, adults and dislocated workers for entry into the labor market, and to provide job training to
those individuals who face serious barriers in obtaining productive employment ("said Program").
D. EMPLOYER is able and willing to train eligible unskilled applicants for entry into the labor
market and is willing to operate said program pursuant to the WIA and applicable federal, state and local laws.
WHEREFORE, for and in consideration of the respective and mutual covenants and promises
hereinafter contained and made, and subject to all the terms and conditions hereof, the parties hereto do hereby
agree as follows:
1. Term. The effective term of this Agreement is for the period beginning August 16, 2010,
and ending November 5, 2010. The term of this Agreement may be extended upon agreement of all
parties and execution of an amendment of the term.
2. Scope of Work. The EMPLOYER shall employ and train one employee (hereinafter "Trainee") in the
occupation and in accordance with the OJT Training Outline set forth in Exhibit A, attached hereto and
incorporated herein by this reference.
Said Trainee shall be referred by the City of Santa Ana W/O/R/K Center. Training must significantly
raise the Trainee from his/her prior position in both level of skill and salary by the end of the training
period.
3. Fundinl_. CITY shall reimburse the EMPLOYER an amount not to exceed 1-4 . 037 in accordance
with the Cost Computation included in Exhibit A. EMPLOYER shall bill the CITY monthly on an
invoice provided by CITY for actual and reasonable cost for providing the services described in this
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Agreement. Reimbursement of EMPLOYER under this Agreement shall be limited to the costs incurred
during the basic work week, excluding overtime and any paid holidays or sick leave.
4. Subcontracting Prohibited. The EMPLOYER shall not subcontract or assign the OJT Training. Any
attempt by the EMPLOYER to delegate or assign OJT training duties under this Agreement shall void,
and permit CITY to immediately terminate, this Agreement.
5. Employer Obligations. During the training, the EMPLOYER shall ensure that the Trainee:
a. is on the EMPLOYER's payroll, not paid as a contracted employee/independent contractor; and,
b. receives the same benefits as EMPLOYER's other employees performing similar work; and,
c. is paid the salary as indicated in Exhibit A with appropriate payroll taxes withheld and reported;
and,
d. is provided Worker's Compensation Insurance coverage, pursuant to state law; and,
e. is provided by EMPLOYER with safety instructions and equipment necessary for reasonable
protection against injury and damage. CONTRACTOR shall maintain appropriate standards for health
and safety in work and training situations. Where special clothing or equipment is provided to the
EMPLOYER's regular employees, EMPLOYER shall provide the same type of clothing or equipment to
the Trainee performing similar work.
6. Employment of Trainee. The EMPLOYER shall employ the Trainee as a regular member of
EMPLOYER's work force. If EMPLOYER wants to continue to employ the Trainee upon the successful
completion of the training period under this Agreement, said employment shall be subject to the same
conditions of employment applied to EMPLOYER's other regular employees, including termination for
unsatisfactory performance.
7. Patent. Copyrights and Rights in Data. The EMPLOYER will disclose to the CITY any invention,
written product, computer program developed or data assembled as a result of performance of work under this
Agreement within seventy four (74) days of invention, development or assembly. The CITY, State of
California, and U.S. Department of Labor will have the right to patent any invention and copyright any written
product or computer program or data generated by EMPLOYER. Upon written request, EMPLOYER will
transfer all pertinent information, specifications and right, title and interest to the designated agency.
8. INVENTIONS, PATENTS AND COPYRIGHTS.
A. Reporting Procedure. If any project produces patentable items, patent rights,
processes, or inventions in the course of work under a U.S. Department of Labor (DOL) grant or agreement, the
CONTRACTOR shall report the fact promptly and fully to the CITY. The CITY shall report the fact to the
Grant Officer, at the DOL. Unless there is a prior agreement between the CITY and the DOL and its
representative on these matters, the DOL shall determine whether to seek protection on the invention or
discovery. The DOL and its representative shall determine how the rights in the invention or discovery,
including rights under any patent issued thereon, will be allocated and administered in order to protect the
public interest consistent with the "Governmental Patent Policy" (President's Memorandum for Heads of
Executive Departments and Agencies, August 23, 1971, and Statement of Government Patent Policy).
B. Copyright Policy.
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1. Unless otherwise provided in the terms of the grant or agreement, when copyright-able
material is developed in the course of or under a DOL Grant or agreement, the author and the CITY which
developed the work is free to copyright material or to permit others to do so. The EMPLOYER and the
Workforce Investment Board (WIB) shall have a royalty-free, nonexclusive and irrevocable license to
reproduce, publish, use and to authorize others to use all copyrighted material.
2. The DOL reserves a royalty-free, nonexclusive, and irrevocable license to reproduce,
publish or otherwise use, and to authorize others to use, for Federal Government purposes: (a) The copyright in
any work developed under any grant, sub-grant, or contract under a grant or subgrant; (b) Any right of copyright
to which a grantee, subgrantee or a EMPLOYER purchases ownership with grant support; and (c) EMPLOYER
shall comply with the requirements of 29 CFR Part 97.34.
C. Rights to Data. The DOL and the CITY shall have unlimited rights to any data first
procured or delivered under this Agreement.
9. Hold Harmless. The EMPLOYER shall indemnify, defend and hold harmless CITY, and its officers,
agents and employees, from and against any and all damages to property or injuries to or death of any
person or persons, including property and employees or agents of CITY, and shall indemnify, defend
and hold harmless CITY, and its officers, agents and employees, from any and all claims, demands,
suits, actions or proceedings of any kind or nature, including, but not limited to, workers' compensation
claims, resulting from or arising out of the negligent acts, errors or omissions of EMPLOYER, its
employees, agents or subcontractors.
10. Insurance. The EMPLOYER shall obtain at its sole cost and file with the City of Santa Ana - Santa Ana
W/O/R/K Center, upon execution of this Agreement, and maintain for the period covered by this
Agreement, a policy or policies of commercial general liability insurance or a certificate of such
insurance, satisfactory to the City Attorney of CITY, naming CITY, and its officers, agents and
employees, as insured or additional insured (see attached Additional Insured Endorsement, Exhibit C),
which provides coverage not less than that provided in the form of a comprehensive general liability
insurance policy against liability for any and all claims and suits for damages or injuries to persons or
property resulting from or arising out of operations of EMPLOYER, and its officers, agents, or
employees. Said policy or policies of insurance shall provide coverage for both bodily injury and
property damage in no less than One Million Dollars ($1,000,000). Said policy or policies shall also
contain a provision that no termination, cancellation or change of coverage or of insured or additional
insured shall be effective until after thirty (30) days notice thereof has been given in writing to CITY.
EMPLOYER shall give to CITY prompt and timely notice of claims made or suit instituted against said
policy. EMPLOYER shall procure and maintain at its own costs and expense, any additional kinds and
amounts of insurance which, in its own judgment, may be necessary for its proper protection.
it. Record Keeving. CITY, the State of California and the United States government and/or their
representatives shall have access for purposes of monitoring, auditing and examining of EMPLOYER'S
activities, performance, books, documents, papers, and records of EMPLOYER'S subcontractors,
bookkeepers and accountants, and employees and participants related to this Agreement. Such agencies
or representatives shall also schedule on-site monitoring in their discretion. Monitoring activities may
also include, but are not limited to, questioning employees and participants and entering any premises or
onto any site in which any of the services or activities funded hereunder are conducted or in which any
of the records of EMPLOYER are kept. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
In the event EMPLOYER does not make the above-referenced documents available within the City of
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Santa Ana, California, EMPLOYER agrees to pay all necessary and reasonable expenses incurred by
CITY in conducting any audit at the location where said records and books of account are maintained.
All accounting records and evidence pertaining to all costs of EMPLOYER and all documents related to
this Agreement shall be kept available at the location where EMPLOYER conducted the program, as
well as in the County of Orange, for the duration of this Agreement and thereafter for three (3) years
after completion of an audit. Records which relate to (a) complaints, claims, administrative proceedings
or litigation arising out of the performance of this Agreement, or (b) costs and expenses of this
Agreement to which CITY, the State of California or the United States Government take exception, shall
be retained beyond the three (3) years until resolution of disposition of such appeals, litigation, claims,
or exceptions.
12. Government Fundina. This Agreement is valid and enforceable only if sufficient funds are made
available to the State by the United States Government for the same Fiscal Year as for this Program. In
addition, this Agreement is subject to any additional restrictions, limitations, or conditions enacted by
Congress or any statute enacted by Congress which may affect the provision, terms or funding of this
Agreement in any manner.
13. Payment Can. Based on the size of EMPLOYER, CITY's OJT payments to EMPLOYER shall not
exceed a maximum of fifty percent (50%) of the wages paid by EMPLOYER during the training period
specified in Exhibit A.
14. Amendment of Agreement. No alteration or variation of the terms of this Agreement shall be valid
and/or binding unless made in writing and signed by both parties. There are no oral understandings or
agreements between the parties.
15. Breach/Sanctions. If, through any cause, EMPLOYER violates any of the terms and conditions of this
Agreement, or if EMPLOYER reports inaccurately or if any Audit Report makes disallowances,
EMPLOYER shall promptly remedy its acts or omissions and/or repay CITY all amounts due CITY as a
result of EMPLOYER's violation. For any such failures or violations, CITY shall also have the right at
its sole discretion to either: (1) discontinue program support until such time as EMPLOYER fulfills its
obligations or remedies all violations of this agreement or prior agreements; and/or (2) collect
outstanding amounts as determined by CITY due CITY by offsetting or debiting from current claims or
invoices, if after thirty (30) days' written notice EMPLOYER has failed to repay same or a repayment
schedule has not been made; and/or (3) terminate this Agreement by giving written notice to
EMPLOYER of such termination in accordance the notice provision in Paragraph XVIII herein below.
16. Termination. Either party may terminate this Agreement upon thirty (30) days prior written notice to the
other party. However, the CITY may immediately terminate this Agreement at such time as funds are
not made available to CITY through the United States Department of Labor or the State of California
Employment Development Department for the purpose of carrying out this Agreement.
17. Independent Contractor. The EMPLOYER, and any agents and employees of the EMPLOYER, in the
performance of this Agreement, shall act in an independent capacity as independent contractors and not
as officers, employees, or agents of the CITY. This Agreement is not intended nor shall it be construed
to create an employer-employee relationship between EMPLOYER and CITY, nor a joint venture
relationship. The EMPLOYER shall not subcontract in the name of the CITY.
18. Equal Employment Onportunities. The EMPLOYER warrants that it will comply with Title VI of the
Civil Rights Act of 1964, and the requirements relating to equal employment opportunities set forth in
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Executive Order No. 11246, as amended by E.O. 11375 and supplemented by the requirements of 41
CFR Part 60. EMPLOYER will also comply with all applicable federal and state laws and regulations,
and particularly those assurances and certifications set forth in Exhibit B attached hereto and by this
reference incorporated herein.
19. Prohibitions. The EMPLOYER shall not use any of the training funds provided under this Agreement
for political or sectarian activities.
20. Grievance Procedure. The EMPLOYER shall continue to operate, or shall establish and maintain a
grievance or complaint handling procedure relevant to the terms and conditions of employment and the
EMPLOYER's activities and programs, which shall meet at a minimum the requirements set forth in
Section 101(31) of the Act and 663.700-710 and regulations promulgated by the State or Federal
Government. Employers that do not have a grievance or complaint handling procedure shall use the
procedures prescribed by the CITY.
21. Guidelines. The CITY shall make the WIA applicable federal regulations and policy guidelines
available to EMPLOYER at CITY - W/O/R/K Center, 1000 E. Santa Ana Blvd., Suite 200, Santa Ana,
California 92701. The CITY shall also inform the EMPLOYER of changes in the WIA regulations or
policy guidelines if such changes affect the operation of this Agreement.
22. Drug Free Workplace. The EMPLOYER agrees to provide a drug-free work place and to execute a
certification as set forth in Exhibit D attached hereto and incorporated herein by this reference.
23. Notices. All notices, reports and correspondence between the parties hereto respecting this Agreement
shall be in writing and deposited in the United States mail, postage prepaid, addressed as follows:
CITY:
City of Santa Ana - Santa Ana W/O/R/K Center
1000 E. Santa Ana Blvd., Suite 200
Santa Ana, CA 92701
Attention: WORK Center Director
EMPLOYER:
Goodwill Industries of Orange County
410 N. Fairview Street
Santa Ana, CA 92703
Phone: (714) 638-1741
Fax: (714) 638-4497
Attn: Cassandra Tobey
24. Debarment. To protect the public interest and ensure the integrity of Federal programs, CITY may only
conduct business with responsible persons and may not make any award or permit any award to any
party which is debarred or suspended or is otherwise excluded from or ineligible for participation in
Federal assistance programs under Executive Order 12549, "Debarment and Suspension". See also 29
CRF Parts 97.35 and 98.510. EMPLOYER must review and sign Exhibit E "Debarment", which is
attached hereto and incorporated herein by this reference.
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24. Merger. This Agreement, together with the attachments hereto, expresses the total understanding of the
parties. There are no oral understandings of the parties or terms and conditions other than as stated
herein.
25. Validity. The invalidity in whole or in part of any provision of this Agreement shall not void or affect
the validity of any other provision of this Agreement.
26_ Miscellaneous Provisions.
a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and
right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully,
including reasonable costs and attorney's fees, for any injuries or damages to CITY in the event that such
authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body
of this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above
written.
ATTEST: CITY OF SANTA ANA
• z Gam-
Maria D. Huizar David N. Ream
Clerk of the Council City Manager
APPROVED AS TO FORM: EMPLOYER:
Joseph W. Fletcher
City Attorney
By: Lisa Storck Name: N cy A. Quarles, M_R_A
Assistant City Attorney Title: Vice President, Human Services
Tax ID#: 91-00658
RECOMMENDED FOR APPROVAL:
Cynthia J. Nel on, Deputy City Manager for
Development Services
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Agreement # Exhibit A
TRAINING PLAN
1. GENERAL
1. Name of OJT Employer: Goodwill Industries of Orange County
2. Address of OJT Work-site: 12371 Lewis St. # 103. Garden Grove. CA 92840
3. Phone Number: 714-678-1460
4. Training Supervisor: Cassandra Tobey
5. Name of OJT Trainee: John Nelson
6. Case Number of Trainee: 1012178
7. Enrollment Component Number of Trainee: 201 (WIA - Adult w/ low income)
8. Proportion of trainees/employees: (at time Agreement entered into)
a. Total number of employer's regular employees 1200
b. Number of Trainee (this Agreement) 1
C. Cumulative number of trainees currently in OJT 1
II. OCCUPATION AND ON-THE-JOB TRAINING OUTLINE:
1. Vendor
2. Occupation/Product or Service: Eligibility Interviewer. Government Program
3. Length of Time in Business: 84 years
4. ONET Code: 43-4061.00 SVP Level 6.0-7.0
5. Hourly Starting Wage: $16.82
Start Date: 08/16/2010 End Date: 11/5/2010
Hours 480 or Days or Weeks
6. State and Federal Tax I.D.: State 91-00658
Federal 95-1644018
7. Basic Work Week Hours: 40
1
8. Outline of On-the-Job Training Plan and Method of Assessment:
ELEMENTS OF TRAINING HOURS OF TRAINING
1. Trainee will be responsible for all program recruitment of clients to the program by: 120
a. Establishing relationships with community and government organizations to
obtain referrals
b. Coordinating, setting up, and presenting at program orientations
Measurement Method: Q & A, task observation and inspection. Goal is to achieve rate of
proficiency within first Month of training.
2. Trainee will maintain information on referral trends and client populations identified as well as 60
determine eligibility for enrollment and potential cost of enrollment, if any_
Measurement Method: Q & A, task observation and inspection. Goal is to achieve rate of
proficiency within first Month and a half months.
3. Trainee will perform administrative duties to support the client enrollment process. Steps 60
include but are not limited to:
a. Creating client folders and logging information into Vertex
b. Obtaining all documentation required by funding source(s).
C. Coordinating with funding sources to receive credit for the appropriate
enrollments
d. Developing class enrollment list and providing to instructor.
e. Scheduling informational sessions and orientations in the community
f. Work with the Program Coordinator on data collection, including development
of forms, input of information into Vertex, and report creation.
Measurement Method: Q 1& A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent two months.
4. Trainee will provide assistance to course Instructor and may be asked to present as a guest 240
speaker or substitute instructor. Trainee will learn course material to provide presentations.
Measurement Method: Q & A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent three months.
RATING LEVELS:
Measurement method: how will it be determined if OJT participant acquired the skill? Q&A, observation, product review/inspection,
etc.
PROFICIENT MODERATE MARGINAL
II. COST COMPUTATION: Based on the business size, hourly reimbursement is calculated at 50 /o of
hourly wage.
Example: (Hourly Reimbursement) X (Hours) _ (Cost Per Trainee)
$8.41 X 480 = $ 4,036.80
III. Person(s) authorized to sign payment invoices for EMPLOYER: Cassandra Tobey
Print Name Signature Title Date
Print Name Signature Title Date
2
ASSURANCES
A. The EMPLOYER assures that:
1. It will comply with the requirements of the Workforce Investment Act (WIA), the California
Unemployment Insurance Code, as amended, and the regulations and policies promulgated
thereunder.
2. No OJT participant displaces a regular employee nor shall an OJT participant fill a position of a
person who has been laid off from the same or similar position.
3. No current employees are receiving unemployment insurance benefits as a result of layoffs or
work reductions.
4. No person in the United States shall on the grounds of race, color, sex, religion, national origin,
age, disability, sexual orientation, or marital status be excluded from participation in, be denied
the benefits of, or be otherwise subjected to discrimination under any program or activity for
which the applicant receives federal financial assistance and will immediately take any measure
necessary to effectuate this Agreement.
5. It will comply with provisions of the Hatch Act, if applicable, which limits the political activities
of employees.
6. Individuals receiving training on the job shall be compensated by the EMPLOYER at such rate,
including periodic increases, as may be deemed reasonable under regulations prescribed by the
Secretary of Labor, but in no event at a rate less than that specified in Section 6 (a) (1) of the Fair
Labor Standards Act of 1938 or, if higher, under the applicable State or local minimum wage
law.
7. Services and activities provided under this Agreement will be administered by or under the
supervision of the EMPLOYER.
8. No relative by blood, adoption or marriages of the EMPLOYER may be trained under this
Agreement.
9. Appropriate standards for health and safety in work and training situations will be maintained.
10. Conditions of employment or training are appropriate and reasonable with regard to the type of
work, the geographical region, and the proficiency of the trainee.
I 1 . Training will not be for any occupation which requires less than six weeks of training according
to the Specific Vocational Preparation Table (SVP Code).
12. Training will, to the maximum extent practicable, be consistent with every individual's fullest
capabilities and lead to employment possibilities.
13. The program will, to the maximum extent feasible, contribute to the occupational development
or upward mobility of individual participants.
14. Training will be in accordance with the training plan, which plan incorporates documentation
that must be completed by EMPLOYER before end of contract.
EXHIBIT B
15. *Dot and **SVP code books will be used to determine length of OJT period. The training time
may not be longer than the SVP Code allows; however, contractors are encouraged to negotiate
shorter training periods whenever applicable.
16. OJT trainees shall not number more than 401/o of the EMPLOYERS work force.
17. All EMPLOYER training payments (reimbursements) must be exclusive of any and all
EMPLOYER fringe benefits, paid holidays, paid sick days and overtime compensation.
18. The participating EMPLOYER must keep an accurate and up-to-date time sheet for the OJT
trainee.
19. Payroll records, time and attendance records and job duties retained on file by the participating
EMPLOYER for each OJT trainee are subject to review.
EXHIBIT B
Certification Regarding
Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The regulations were published
as Part VII of the May 26, 1988 Federal Register (pages 19160-19211).
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION -
Attached)
(1) The prospective recipient of federal assistance funds certifies, by submission of this proposal, that
neither it nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by any federal department or
agency.
(2) Where the prospective recipient of federal assistance funds is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation to this
proposal.
ts)D nr ~~4~ jk- Q1)ra? 1L--51
Name and Title of Authorized Representative
Signature Date
EXHIBIT C
GOODIND-01 MART
~4CORG,„ CERTIFICATE OF LIABILITY INSURANCE DATE
I 7/16/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
D.L.D. Insurance Brokers, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Lic#OD25325 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
17712 Mitchell North ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Irvine, CA 92614
INSURERS AFFORDING COVERAGE NAIC #
INSURED Goodwill Industries of Orange County INSURERA: Philadelphia Insurance Companies
410 North Fairview INSURER B:
Santa Ana, CA 92703-
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' POLICY EFFECTIVE POLICY EXPIRATION
POLICY NUMBER LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMF_RCIALGENF_RALLIABILITY PHPK593330 7/1/2010 711/2011 PREMISES Eaoccurence $ 300,000
CLAIMS MADE EKI OCCUR MED EXP (Any one person) $ 15.00
PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 3,000,00
GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 3.000.00
POLICY PRO X LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALLOWNEDAUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $ STAT_ WORKERS COMPENSATION AND W
TOR CY 11.11-1 IT" ER
EMPLOYERS' LIABILITY
y ggyyy ' '`p ar8 E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE g
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
If yes, tlescribe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
OTHER J ORCK
LISA E. S
Assistant Cit Attorney
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SP IAL PROVISIONS
SeB attached page.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
The City of Santa Ana DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN
20 Civic Center Plaza
M-76 - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Santa Ana, CA 92701- IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) O ACORD CORPORATION 1988
EXHIBIT C
GOODIND-01 MART PAGE 1 OF 1
DESCRIPT:01.: OF OPERATIONS -
Goodwill Industries of Orange County The City of Santa Ana
410 North Fairview
Santa Ana, CA 92703- 20 Civic Center Plaza
M-76
Santa Ana, CA 92701-
Re: Micro-Enterprise Program
1. The City of Santa Ana, its officers, employees, agents and volunteers are Additional Insureds with regard to liability and defense
of suits arising from the operations and uses performed by or on behalf of the named insured per the attached policy form #CG 20
05 11 85.
2. It is agreed that such insurance as is afforded by this policy for the benefit of the additional insured shown shall be Primary
Insurance and any other insurance maintained by the additional insured shall be excess and non-contributory except for Gross
Negligence or Wanton Misconduct on the part of the additional insured, but only with respect to liability arising out of operations
performed for the additional insured by or on behalf of the named insured.
3- This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the
company's limits of liability. The inclusion of any person or organization as an insured shall not effect any right which such person
or organization would have as a claimant if not so included.
4. Please refer to the 30 Day Notice of Cancellation Clause located at the bottom right of the Certificate of Insurance.
10 Day Notice applies in the event of Non-Payment.
TC)
LISA -TORCK
Assistant City Attorney
POLICY NUMBER: PHPK439884 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY- PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED CONTROLLING INTEREST
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Names of Person or Organization:
City of Santa Amma
(if no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement)
'I. WHO 18 AN INSURED (Section 11) is amended to a. Their financial control of you; or
include as an insured the person(s) or organize- b. Premises they own, maintain or control while
tion(s) shown in the Schedule, but only with re-
spect to their liability arising out of: you lease or occupy these premises.
2. This insurance does not apply to structural altera-
tions. new construction and demolition operations
performed by or for that person or organization.
L1S ORCK
City Attorney
E4ssistant
CG 20 05 11 85 Copyright, Insurance Services Office. Inc., 1984 Page 1 of 1 0
Certification Reclardincl Drun-Free Workplace Requirements
The certification set out below is a material representation upon which reliance is placed
by the U.S. Department of Housing and Urban Development in awarding the grant. If it
is later determined that the contractor knowingly rendered a false certification, or
otherwise violates the requirements of the Drug-Free Workplace Act, the U.S.
Department of Housing and Urban Development, in addition to any other remedies
available to the Federal Government, may take action authorized under the Drug-Free
Workplace Act_
CERTIFICATION
A. The contractor certifies that it will provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is
prohibited in the contractor's workplace and specifying the actions that will
be taken against employees for violation of such prohibition;
(b) Establishing a drug-free awareness program to inform employees about -
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee
assistance program; and
(4) The penalties that may be imposed upon employees for drug abuse
violations occurring in the workplace;
(c) Making it a requirement that each employee who will be engaged in the
performance of the grant be given a copy of the statement required by
paragraph (a);
(d) Notifying the employee in the statement required by paragraph -(a) that,
as a condition of employment under the contract, the employee will -
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a
violation occurring in the workplace no later than five days after
such conviction.
Pg. 2
EXHIBIT D
(e) Notifying the U.S. Department of Housing and Urban Development within
ten days after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving actual notice of such conviction;
(f) Taking one of the following actions, within 30 days of receiving notice
under subparagraph (d)(2), with respect to any employee who is so
convicted -
( 1) Taking appropriate personnel action against such an employee, up
to and including termination; or
(2) Requiring such employee to participate satisfactorily in a drug
abuse assistance or rehabilitation program approved for such
purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace
through implementation of paragraphs (a), (b), (c), (d), (e) and (f).
B. The contractor shall insert in the space provided on the attached "Place of
Performance" form the site(s) for the performance of work to be carried out with
the grant funds (including street address, city, county, state, and zip code) .the
contractor further certifies that, if it is subsequently determined that additional
sites will be used for the performance of work under the contract, it shall notify
the U.S. Department of Housing and Urban Development immediately upon the
decision to use such additional sites by submitting a revised "Place of
Performance" form.
Dated:
Progr Operator
DIVISION OF EMPLOYMENT SERVICES
PLACE OF PERFORMANCE
FOR CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS
EXHIBIT D
Name: nl[tt~c ( (~.~c.,/~25
Name of Contractor: 70p s7w IL X\ F O C,
Contractor Number:
Date: 12) 1 % ly I Ql ) 1 D
The Contractor shall insert in the space provided below the site(s) expected to be used
for the performance of work under the contract covered by the certification:
Place of Performance (include street address, city, county, state, zip code for each site):
\23"l 1 l~~w %S ST -VF\ r ~)_3
he rr E,rzcr/ G °125 6 y
EXHIBIT D