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HomeMy WebLinkAboutBOB MURRAY & ASSOCIATES 2-2011INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES ry _? v _? z N-2011-104 CLERK OF COU?I?l? 2 9 2011. DATE: v CONSULTANT AGREEMENT p'. p?rs?n?-1 ?Z? ?.) \C+r?e THIS AGREEMENT, made and entered into this 1st day of July, 201 1 by and between Sh+?leaBob Murray 8z Associates (hereinafter "Consultant"), 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"). RECITALS A. The City desires to retain a consultant having special skill and knowledge to perform employee recruitment services. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: SCOPE OF SERVICES Consultant shall provide recruitment services for the City as set forth in the Proposal attached hereto and incorporated herein as Exhibit A, including but not limited to, attending meetings, advertising, recruiting candidates, screening candidates, public records review, interviews and background check of candidates. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A. The total sum to be expended under this Agreement shall not exceed $25,000.00 during the term of this Agreement. This includes $16,500 for any recruitment, plus reasonable reimbursable expenses. b. City agrees to pay progress payments to Consultant upon submittal of reasonable invoices, with final payment at the end of services rendered. c. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on the date first written above and terminate on June 30, 2012, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended by a writing executed by the Executive Director of Personnel and the City Attorney. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create anemployer-employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, agents, volunteers, and employees as additional insureds) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence. Consultant shall supply City with a fully executed additional insured endorsement in substantially the form attached hereto as Exhibit B upon execution of this Agreement and shall be approved in form by the City Attorney. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non-owned automobiles. c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. 2 d. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (iii) Certificates and policies shall state that the policies shall not be cancelled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. e. If Consultant fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement_ Such termination shall not effect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold hazmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief azising out of claims for personal injury, including health, and claims for property damage, which may azise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 ofthis Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regazding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects azising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of caze it uses to protect its own information of like importance, but in no event less than reasonable caze. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant 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. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: City Clerk City of Santa Ana 20 Civic Center Plaza (M-30) P.O. BOX 1988 Santa Ana, CA 92702-1988 telefacsimile (714) 647-6956 With courtesy copies to: Personnel Department, City of Santa Ana 20 Civic Center Plaza (M-24) P.O. Box 1988 Santa Ana, California 92702 and City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-6515 To Consultant: Bob Murray 8? Associates 1677 Eureka Road, Suite 202 , Roseville, CA 95661 Telefacsimile (916) 784-1085/Phone (916) 784-9080 A party may change its address by giving notice in writing to the other party. Thereafter, any notice, tender, demand, delivery, or other communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. 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 Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, that terms and conditions hereof, shall not bind or obligate Consultant nor 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. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant 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. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12_ TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Maria D. Huizar City Clerk CITY OF SANTA ANA Pa alters Int r City M er APPROVED AS TO FORM: JOSEPH STRAKA Interim City Attorney By: ?1 Lisa Storck Assistant City Attorney APPROVED AS TO CONTENT: Kathie Gonzalez, Executive Director Personnel Services Agency CONSULTANT Regan Williams Vice President TAX ID: 13. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. 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 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. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 16. 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. Exhibit A Bob Murray 8c Associates BUDGET AND TIMING PROFESSIONAL FEE AND EXPENSES The consulting fee for conducting employee recruitment on behalf of the City of Santa Ana is $16,500 plus expenses. Services provided for the fee consist of all steps outlined in this proposal including three (3) days of meetings on site. The City of Santa Ana will be responsible for reimbursing expenses Bob Murray 8c Associates incurs on your behalf. We estimate expenses for this project to be $8,500. Reimbursable expenses include such items as the cost of travel, clerical support, placement of ads, credit, criminal and civil checks, education verification, as well as newspaper searches. In addition, postage, printing, photocopying, and telephone charges will be allocated. TIMING We are prepared to start work on this assignment immediately and anticipate that we will be prepared to make our recommendation regarding finalists within seventy five to ninety days from the start of the search. GUARANTEE We guarantee that should the selected candidate be terminated for cause within the first two years of employment we will conduct the search again at no cost (with the exception of expenses) to the City of Santa Ana. We axe confident in our ability to recruit outstanding candidates and do not expect the City of Santa Ana to find it necessary to exercise this provision of our proposal. 8 EXHIBIT B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # relating to the following: 1. The City of Santa Ana 20 Civic Center Plaza (M-25) P.O. Box 1988 Santa Ana, California 92702; its officers, employees, agents, volunteers and representatives are named as additional insureds ("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. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 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 affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana 20 Civic Center Plaza (M-25) P.O. Box 1988 Santa Ana, California 92702. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective Policy # _ Issued to this endorsement form as a part of Named Insured Countersigned by Authorized Representative OP ID: CJ '`?r?°?O CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 09/1 O/1 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS GERTI FICATE 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 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 endorsements . PRODUCER 916-773-3800 CONTACT NAME: ISU/Francis-Finney Ins. 916 773484 Py A C °O? - 2266 Lava Ridgge Court Ste 200 /c / No Est P. O. Box 619060 EMAIL R ill CA 95661 9050 ADDRESS: osev e, - PRODUCER Bruce Winning MBNSE-1 cusTOMERIOS _____.__. ___ __ INSURER(S) AFFORDING COVERAGE NAIC i INSURED MBN Services Inc. INSURERA:Hartro rd Insurance Group 22367 DBA: Bob Murray 8. Associates INSURER s: Philadel hie Insurance Com an 1677 Eureka Rd Ste 202 INSURERC: Roseville, CA 95661 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW rrH STAN DING ANY REQUIREMENT, TERM OR CON DfTION OF ANY CONTRACT OR OTHER DOCUMENT WfTH 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. LIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ? ILTR TYPE OF INSURANCE POLICY NUMBER MM?D/YYYY MMADNYYY LIM RS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 A X COMMERCIAL GENERAL LIABILITY X 57SBAUZ4977 07/20/11 07/20/12 PREMISES Ea occurrence $ 300,00 CLAIM SMADE O OCCUR MED EXP (Myone person) $ 10,00 A Tyr ?QRNS PERSONAL B ADV INJURY $ 2.000.00 D ?? Q T R? V GENERAL AGGREGATE $ 4,000,00 GEN'L AGGREGATE LIMIT APPLIES PER n gpP +_O __? PRODUCTS- COMP/OP AGG $ 4,000,DD POLICY PR? X LOC , $ AUT OMOBILE LIABILITY ? ?,SA E. S Att C?tY they COMBINED SINGLE LIMIT (F_a accitl an[) $ 1,DDD,DD ANY AUTO w` ,ry Slsta BODILY INJURY (Per person) $ ALL OWNED AUTOS ?? BODILY INJURY (Per accitlent) $ SCHEDULED AUTOS PROPERTY DAMAGE A X HIR ED AUTOS 57SBAUZ4977 07/20/11 07/20/12 (Per accident) $ A X NON-OWNED AUTOS 57SBAUZ4977 07/20/11 07!20/12 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSJNADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WO RKERS COMPENSATION X WC STAT U- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTVE Y/N O ? FFI N / A 57WECFX9562 09/15/10 09/15/11 E.L. EACH ACCIDENT $ 1,000,00 O CER/MEMBER EXCLUDED (Mantl story In NH) E L DISEASE - EA EMPLOYEE $ 1,000,00 If yes, tlesoribe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,00 B Professional E8.0 PH SD596467 02/27/11 02/27/12 OGD/AGG 1,000,00 Rete ntlon 5,00 DESCRIPTION OF OPERAT ONS / LOCATONS /VEHICLES (Attach ACORD tOt, Atltlltlonal RamarNa 3eM1etlule, Ir more apace le roqulre tl) NOTE: 10 Days notice of caneellatlon applies for non-payment of premium. Re: Services provided by the named Insured onlyy. The city of Santa Ana, k's officers employees, agents, and representafives are Included as additional Insured per attached endorsement Waiver of Subrogation Included. CERTIFICATE HOLDER CANCELLATION SANTAII SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Santa Ana tY THE EXPIRATION DATE THEREOF, NOTCE WILL BE DELIVERED IN ACCORDANCE WITH TiE POLICY PROVISIONS. 20 Civic Center Plaza, 8th FI Santa Ana, CA 92701 ALTFIORIZED RE PRESENTATIVE ?.T?. .,L .,.. P?.?7 O 1969-2009 ACORD CORPORATION. All rights reserved. AGORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:57SBAUZ4977 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY ADDITIONAL INSURED AMENDMENT OF CONDITIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organization: SCHEDULE The City of Santa Ana, it's officers, employees, agents and representatives. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. With respect to insurance provided to t}?e person or (1) That is Fire, Extended Coverage, organization shown in the Schedule of this Builder's Risk, Installation Risk or similar Endorsement, Condition 4. Other Insurance is coverage for "your work;" replaced by the following: (2) That is Fire Insurance for premises rented 4. Other Insurance. to you; or (3) If the loss arises out of the maintenance If other valid and collectible insurance is available or use of aircraft, "autos" or watercraft to for a loss we cover under Coverages A and B of the extent not subject to Exclusion g. of this Coverage Part, our obligations are limited as Coverage A (Section I). follows: When this insurance is excess, we will have a. Primary Insurance no duty under Coverage A or B to defend any This insurance is primary and we will not seek claim or "suit" that any other insurer has a contribution from other insurance available to duty to defend. If no other insurer defends, the person or organization shown in the we will undertake to do so, but we will be Schedule of this endorsement except when b. entitled to the insured's rights against all below applies, those other insurers. b. Excess Insurance When this insurance is excess over other This insurance is excess over any of the other insurance, we will pay only our share of the insurance whether primary, excess, amount of th? if any, that exceeds the oTQ F contingent or on any other basis: pgpV£? ? S, ORGY, Form HC 2408 11 94 City Attorney Page 1 of 2 ?S ? t p ssis ? ? O 1995 The Hartford Insurance Group (Includes copyrighted mate rial of Insurance Services Office with its permission Copyright , Insurance Services Office, 1995) (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self-insured amounts under all [hat other insurance. We will share the remaining loss, if any, with any other insurance that is not described in the Excess Insurance provisions and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. APPROVED RS TO FORM 1_.ISA E. STORCK Assistant City Attorney 3?,? Page 2 of 2 Form HC 24 OS 11 94 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT m °Policy Number: 57 wEC Fx9552 Endorsement Number. 12 Effective Date: 11/17/10 Effective hour is the same as stated on the Information Page of the policy_ ? Named Insured and Address: MBN SERVICES INC DBA N N ? 1677 EUREKA ROAD, STE 202 X ROSEVILLE, CA 95661 w We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not o enforce our right against the person or organization named in the Schedule. 0 This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE WOS ANY PERSON OR ORGANIZATION FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. Ag TO FpPl`? ® gpFRO??p S-` C) RCK LISA E• `t Attorney Assistant C Y J Countersigned by Authorized Representative Form WC 00 03 13 Printed in U.S.A. Process Date: 12/07/10 Policy Expiration Date: 09/15/11