HomeMy WebLinkAboutOH INSURANCE AGENCY/ALLSTATE INSURANCE AGENCY 3 - 2012Agreement No.
G pL4- / W oar K C?r-s}er
INSURANCE ON FILE
VvORK (NAY rROCEED
UN'iIL INSURANCE EXPIRES
CLERK OF COUNCIL
DATE: JUL 1 6 2??2
O pOY?Q l-?c?? u tYl ON-THE-JOB TRAINING AGREEMENT
UNDER THE WORKFORCE INVESTMENT ACT
N-2012-081
i zio9
THIS AGREEMENT is made and entered into this 31st day of May, 2012 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 Oh Insurance Agency/AllState Insurance Agency (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
1 16 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 Monday. June 4th. 2012, and
ending November 2°d, 2012. 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. Funding. CITY shall reimburse the EMPLOYER an amount not to exceed X4,400 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 Agreement.
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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. Subcontractine 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. Emx>lover 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).
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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 aroyalty-free, nonexclusive and irrevocable license to
reproduce, publish, use and to authorize others to use all copyrighted material.
2. The DOL reserves aroyalty-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.
1 O. 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.
11. Record Keeping. 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.
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In the event EMPLOYER does not make the above-referenced documents available within the City of
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 Fundine. 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 Cap. 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.
1 8. Equal Employment Opportunities. The EMPLOYER warrants that it will comply with Title VI of the
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Civil Rights Act of 1964, and the requirements relating to equal employment opportunities set forth in
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. Dru>? 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:
Oh Insurance A?ency
All State Insurance Aeency
1421 Warner Ave.. Suite D
Tustin, CA 92780
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. Mercer. 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:
?? ? ?/?"
Mana D. Huizar
Clerk of the Council
APPROVED AS TO FORM:
Lisa Storck
Assistant City Attorney
CITY OF SANTA ANA
Paul Walters
Interim City Manager
EMPLOYER:
V a ?_
By: Lisa torck N me: Janet Oh
Assistant City Attorney itle: Executive Manager
Federal Tax ID#: 33-0937743
State Tax ID#: 464-9440-7
RECOMMENDED FOR APPROVAL:
? 1 Ol/T7 ?`I ?.-??GC?L??
Nancy "I'. Ed rds
Interim Executive Director
Community Development Agency
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Agreement # Exhibit A
TRAINING PLAN
I. GENERAL
1 . Name of OJT Employer: Oh Insurance Agency/All state Insurance Agency
2. Address of OJT Work-site: 1421 Warner Ave., Suite D, Tustin, CA 92780
3. Phone Number: 714-247-1030
4. Training Supervisor: Janet Oh
5. Name of OJT Trainee: Stephanie Ewing
6. Application Number of Trainee: N/A
7. Proportion of trainees/employees: (at time Agreement entered into)
a. Total number of employer's regular employees 8
C. Cumulative number of trainees currently in OJT 0
II. OCCUPATION AND ON-THE-JOB TRAINING OUTLINE:
1. Program #: DOL-TECH
2. Occupation/Product or Service: Customer Service Rep/ Insurance Agent
3. Length of Time in Business: 13
4. ONET Code: 43-4051.00/41-3021.00 SVP Level (4.0 to <6.0)/(7.0 to-<8.0)
5. Hourly Starting Wage: $10
Start Date: 6/04/2012 End Date: 11/02/2012
Hours 880 or Days or Weeks
6. State and Federal Tax I.D.: State: 464-94407
Federal: 33-0937743
7. Basic Work Week Hours: 40
Outline of On-the-Job Training Plan and Method of Assessment:
ELEMENTS OF TRAINING HOURS OF TRAINING
1. Will be trained to support the agency by developing exceptional customer 280
service. Develop client relationship through a courteous and prompt customer
interaction.
a. Preparation for Pre-licensing class (class is 2 weeks long)
b. Practical knowledge and development of insurance industry, including
language, practices, forms, etc.
c. Familiarize with different types of policies, including: fire, life, auto,
property, medical.
d. Interview clients to obtain pertinent data about financial resources and
needs, physical condition of persons/property to be insured, discuss existing
policies
Measurement Method: Q & A, task observation and inspection. Goal is to achieve rate
of proficiency within first Month and a half of training.
2.
a. Learn to call policyholders to deliver and explain policy, to analyze 220
insurance programs and suggest additions or changes to change beneficiaries.
b. Learn to send out introductory letters regarding agency and prompt service
requirements.
c. Learn to follow up on all referrals and leads.
d. Learn to send out thank you cards for referrals.
Measurement Method: Q Sk A, task observation and inspection. Goal is to achieve rate
of proficiency within subsequent three and a half months.
3.
a. Learn to sell various types of insurance policies to business and individuals 260
on behalf of insurance companies, including automobiles, fire, life, property,
medical and dental insurance or specialized policies such as marine, far/crop
and medical malpractice.
b. Learn to interview prospective clients to obtain data about their financial
resources and needs, the physical condition for the person or property to be
insured, and to discuss any existing coverage.
c. Learn features of various policies to be able to promote sale of insurance
plans.
Measurement Method: Q & A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent three and a half months.
ELEMENTS OF TRAINING HOURS OF TRAINING
4.
a. Learn to seek out new clients and develop clientele by networking to find 120
new customers and generate lists of prospective clients.
b. Learn how to insure that policy requirements are fulfilled, including any
necessary medical examinations and the completion of appropriate forms.
c. Learn to confer with clients to obtain and provide information when claims
are made on a policy.
Measurement Method: Q 8c A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent three and a half months.
RATING LEVELS:
Measurement method: how will it be determined if OJT participant acquired the skill? QBcA, observation, product review/inspection,
etc.
PROFICIENT
II.
III
COST COMPUTATION
MODERATE
Example: Hourly Reimbursement at 50% $5.00
_ $ 4.400.00
MARGINAL
Hours 880 cost Per Trainee
Person(s) authorized to sign payment invoices for EMPLOYER:
Print Name
Print Name
S' n re
Signature
??c?? ?
I?IQ rac-sL ? ?' ? ? 1 ?'?? 12
Title Date
Title
Date
3
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 marriage 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.
1 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.
15. *Dot and **SVP code books will be used to determine length of OJT period. The training time
EXHIBIT B
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 40% 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
EMPLOY/?E,R for each OJT trainee are subject to review.
?e v ce Provider Signature Date
Print First Name
_ Oh Insurance A?ency/Allstate Insurance
Organization Name
Print Last Name
1421 Warner Ave.. Suite D, Tustin. CA 92780
Organization Address
EXHIBIT B
OG/Y2/2012 13:20 FAX 7142471031
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OH INSURANCE AGENCY TH13 CERTIFICATE I: ? IS3VED q3 A MATTER OF INFORMATIOr
ONLY AND CONFEF S NO RIGHTS VPON THE CERTIF=KATE
1421 WARNER AVE. $TE_ D ALOTLER RTHEHCOYEFZ4 GE AFFORDED BYO 7HE POLDIGE STE9EOLOW
TUSTIN, CA 92780
INSUREp _-. _... INSURERS AFFORDING COVERAGE NAIC _#_
JANET J. OH INSURER A ALLSTATE I(` SURANC;E COMPANY
DBA OH INSURANCE AGENCY INSURER B: F D I VSLIRAN? ? '
T421 WARNER AV E. STE_ d ENSURER C: --
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COVERAGES INSURER E: ? -`
I THE POLlGIES OF INSURANCE LISTED BELOW HgVE 6EEN ISSUED TO 7HE INSURED NAMED ABOVE FOR TH c POLICY PERIOD IN DICATEO. NO7WITHS7ANDING
ANY REOUIREMEN7. TERM OR CONDITION OF ANY CONTRACT OR OTHER ?OCUMENT WITH RESPECT 7 ? WHICH -rNIS CERTIFICATE MAY 6E ISSUED OR
MAY PERTAIN, 7HE INSURANCE AFFORDED E)Y THE POLICIES AESCRI6ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE OEEN REDUCED BY PAID CLAIMS,
NaR Dri•
POLICY NUMBER PO ICY EFFECTIVE POLICY EXPIAL rIO1V -?
GENERAL LViBILIry LIMITS
X COMMERCIAL GENERAL LIABILITY 50661033 EACH OCCURRENCE § 2,000,000
06/16/2012 06/16/207:: A?T67SEArED-
A K CLAIMS MADE O pCCVR P ISES (Eno -euron S 2,000,QQQ
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OTHER E. L. DISEASE-POLICY LIMIT S 1 OC
DESCRIPTION OF OPERATIONS/ LOGATONS /VEHICLES / EXCLVSIONg ADDED BY ENpORSEMENT / SPECIAL PROVISIONS
CertificatQ holder, its officers, agents, and employees a ra Warned as Additional Insured i
CG 2015 11/88 n regard: to General Liability per a ed
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10 d TO FQ
ays notice of cancellation for nonpayment. AS
AppR,pV£D
:ERTIFICATe HOLDER X ADDI"T"IONAL TIVS?URED X CANCELLATION ``,, -?
CITY OF SANTA ANA SNOULpgNYOFTNEA C21BE.p_t aLYIC?iE`??A LED 6EFORE THE EXPIRATION
ATTN: PURCHASING DEPARTMENT GATE THEREOF, THE ISSUING INSVBBAx?EL'ENOEAVOR TO MAIL 9O DAYS WRITTEN
20 CIVIC CENTER PLAZA NOTICE TO THE CERTIFICATE HOLIF'??E?R''N_AMED TO THE LEFT, BUT FAILURE Tp DD SO SHALL
SANTA ANA, GA 92701 IMPOSE NO OBLIQATION OR LIABI _ITY OF ANY K)NO UPON THE INSURER, 179 AGENT9 OR
REPRESENTATIVES.
AUTHORIZED REPRESENT VE
CORD 25 (2007/08)
m ACORD CORPORATION 1988
OH INS AGENCY-ALLSTATE
Exhibit C
00/12/2012 13;_19 FAA 7142471031 OH INS AGENCY-ALLSTATE
t?jool/o02
ACORD?, CERTIFICATE OF LIABILITY INSURANt:E D 06/12/12?YI
PRODUCER THIS CERTIFICATE IS I: )SUED AS A MATTER OF INFORMATION
OH INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON YHE CERTIFICATE
HOLDER. THIS CERTIF CATE DOES NOT AMEND, EXTEND OR
1421 WARNER AVE. STE. D ALTER THE COVERAGI: AFFORDED BY THE POLICIES BELOW.
TUSTIN, CA 92780
_ INSURERS AFFORDING C OvERAGE NAIC #
_ _.
wsDREp ????•^ ? IysuRER A? _ALLSTATE_INS JRANCE COMPANY _, _„_
JANET J. OH
DBA OH INSURANCE AGENCY
1421 WARNER AVE. STE- D
TUSTIN, CA 92780
r_.-IVF1?nGFs
THE POLICIES OF INSURANCE LISTED BELOW HAVE 6EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN7 WITH
ANY REQUIREMENT RESPECT TC WFIICH YIiIS CERTIFICATE MAY BE ISSUED 6R
.
MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SU 6J ECT TO ALL THE ? ERMS, EXI?LVSIO NS AND CONDITIONS OF SUCH
PouGES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- _ _
INSR DD' POLICY NV MBER POLICY EFFECTIVE POLICY E PIRMI ON LIMITS
GENERAL uABIUTY EACH OCCURRENCE S 2.000,000
50661033 06!16/2012 ?tr $ 2000
06/16/2013
000
?o
?
X COMMERCIAL GENERALUg01LITY ,
P
E
o
CLAIMS MADE O OCCUR MED E%P (Any one paraafl % 1 ,000,000
A K PERSONAL&ADV INJURY y 1.000,000
GENERAL AGGREGATE $ 50.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG 5 1, 000
POLICY PRO• LOG
AUT OMOBILE LIABILITY COMEINED SINGLE LIMIT S
ANY AUTO lEa sm:itlenq
-
ALLOWNEDAUTOS BODILY IN.)URY $
SGHED V LED AUTOS (Per p•3rGOn)
-
HIREDAVTOS BODIIY INJURY $
OWNED AUTOS
NON (Per eeeitlenp
-
PROPERTY DAMAGE $
(Per accitleM)
GARAGE LIABILITY AUTG ONLY - EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC 5 _
AUTC?ONLY: qGD S
EXCESSiUMBRELLA LIABILITY EACH OCCURRENCE % _._
OCCUR ? CLAIM6 MADE AGGREGATE %
J
$
EDUCTIBLE _
? ?
-
D ..? -?
RETENTION §
WC STATU• OTH-
WORKERS COMPEN6ATION AND
EMPLOYER6'LIABIUTY 83 WEC J26626 10/13/11 1D/13/12 E. L. IiAChI ACCIDENT S 1.01)?,ODp
13 ANY PROPRIETOR/PARTNERlEXECUTIVE
OFFICERIMEMBER EXCLUDED9
E.L. IJISEASE • EA EMPLOYE
- % 1 ,000,000
II ea. tlosC/ibe untler E
L
DISEASE-POLICY LIMIT S i ??O90?
SPECIAL PROVI IONS below .
.
OTHER
DESCRIPTION OF OPERATONS I LOCATIONS / VEHICLES I E%CLV $IONS ADDED BY ENDORSEMENT /SPECIAL PROVI610NS
Certificate holder, its oFFicers, agents, and employees are named as Additional Ins ured in rega •ds to General Liabilitv?er??>fl(I¢,?.
CG 2015 11 /88 OV yI y AS
pR
Ap
10 days notice Df eaneallatlGn for nonpayment.
CERTIFICATE HOLDER K ADDITIONAL INSURE'.D X CANCELLATION -? Ltar, - torn=?
SHOULD ANY OP THE ABOVEC EgC? I BE CANCELLED BEFORE THE EXPIRATION
CITY OF SANTA ANA DATE THEREPF, THE 166UING INSVR6R WILL ENOEAVOR'f0 MAIL 3O DAYS WRITTEN
ATTN_ PURCHASING DEPARTMENT
20 CIVIC CENTER PLAZA NOTICE YO THE CERTFICATE iOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 30 9HAL4
SANTA ANA, GA 92701 IMPOSE NO OBLIGATION OR ./ABILITY OF ANY KING UPON THE INSURER, ITS AGENTS OR
REPRESENYATIVES.
AUTHORIZED REPRESENT VI
_ ?...r....,? ..... n.I ir,n• / C6) ACORD CORPORATION 1888
EXnibit c
06/12/2012 13:19 FAX 7142471031 OH INS AGENCY-ALLSTATE [7j 002/002
NAMED INSURED: JANET J OH OBA OH INSURANCE AGENCY
POLICY NUMBER 5p661033
PplICY EFFECTIVE DATE: p6/16/2012 POLICY EXPIRATION DATE: 06/16/7 013
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ fT CAREFULLY
ADDITIONAL INSURED -VENDORS
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLD\ VING:
COMMERCIAL GENERAL LIABILITY COVERAGE Pi ART.
PRODUCTS /COMPLETED OPERATIpN LIABILITY COVER 4GE PART.
SCHEDULE
DESCRIPTION OF OPERATIONS:
City of Santa Ana, its officers, agents and employees
20 Civic Center Plaza
Santa Ana, Ca 92701
(If no entry appears above, information required to complete this en iorsement will be shown
in the Declarations as applicable to this endorsement.
AS TO FORM
APPROVED
LISA E?iSTORCK
assistant City Attorney
?l?
CG2015 11 $$
Exhibit C
Certification Regarding Drug-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 adrug-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 adrug-free awareness program to inform employees about -
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining adrug-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.
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;
EXHIBIT D
(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 adrug-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: 5/31 /12 /? /L- `-'-
Program Operator
EXHIBIT D
DIVISION OF EMPLOYMENT SERVICES
PLACE OF PERFORMANCE
FOR CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS
Name: Oh Insurance Agency/Allstate Insurance
Name of Contractor: Janet Oh
Contractor Number:
Date:
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):
1421 Warner Ave.. Suite D.
Tustin. CA 92780
EXHIBIT D
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.
Janet Oh- Executive Manager
Name and Title of Authorized Representative
S
1/12
Date
EXHIBIT E
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective recipient of federal assistance funds is
providing the certification as set out below.
2. The certification in this clause is a material representation of fact upon which reliance was placed
when this transaction was entered into. If it is later determined that the prospective recipient of
federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies
available to the Federal Government, the Department of Labor (DOL) may pursue available
remedies, including suspension and/or debarment.
3. The prospective recipient of federal assistance funds shall provide immediate written notice to the
person to which this proposal is submitted if at any time the prospective recipient of federal
assistance funds learns that its certification was erroneous when submitted or has become erroneous
by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered
transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and
"voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the person to
which this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective recipient of federal assistance funds agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier
covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this covered transaction, unless authorized by the DOL.
6. The prospective recipient of federal assistance funds further agrees by submitting this proposal that
it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and
voluntary exclusion - Lower Tier Covered Transactions," without modification, in all lower tier
covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded
from the covered transaction, unless it knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the eligibility of its principals. Each
participant may, but is not required to check the List of Parties Excluded from Procurement or Non-
Procurement Programs.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge and
information of a participant is not required to exceed that which is normally possessed by a prudent
person in the ordinary course of business dealings.
9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the Federal Government, the DOL may pursue available
remedies, including suspension and/or debarment.
On the Job Training Pre Award 'S,_urvey
BUSINESS NAME: {??-?- ??/?C;ti(?GI,(/?,(?? A?jylc,? STATE TAX I.D. # `?? ?9?y? '
ADDRESS: Huai ularrur«-v? 3 -p937??f
?'???`? ? FEDERAL TAX I.D. # 3 -3
YES NO
1 . The business does provide worker's compensation coverage. ? ?
Policy Number: SO (o ?i?? p ? ?j
2. The business does provide General Liability Insurance in the amount of ? ?
One Million Dollars ($1,000,000). Policy must identify the City of Santa Ana as
the certificate holder.
3. The system used for business accounting does document cash received, state and
federal tax withholdings, FICA deductions. ?
4. The business has not been cited for any health, safety, wage and hour, or child
labor violations during the past 12 months. []
5. The business maintains a grievance and/or complaint handling procedures for ? ?
employees.
6. The prospective OJT client is not a former employee of the business.
7. Wages for the planned OJT position are wages comparable to similar positions. ?? ?
g. A written job description for this position is on file. ?? ?
9. Union concurrence has been obtained. ? n]`? ?
10. Business license is current.
1 1 . The business has not had any employees laid off in the past 6 months.
12. The business is financially stable and has the means to train and pay for the
prospective OJT employee. ? / ?
The employer stipulates and agrees by signing below that the establishment in which ?onY-the job
training will be given:
(1) Has not been moved from any previous location less than ] 20 days prior to the effective date of the
OJT contract.
(2) Is not a branch, affiliate or subsidiary of a business entity in another location which has, at any time
subsequent to the date of the OJT contract, relocated or expanded so as to cause an increase in
unemployment or the closing down of operations in which the entity conducts business operations.
TOTAL WORKFORCE # ? CONTRACT RECOMMENDED YES ? NO ?
Comments:
Lll//l ?1 ? ? ? 3l /ZOO ? Z
?p yer Title Date
ar
dJT Coo/?'r?tFir(atdr/ se Manager ? Gate
//`r c-> ?-?? 0 I `- ?-
Progra Supervisor/Director Date
On the Job Training Agreement Checklist
BUSINESS NAME: ?" ?`C? ??iYlC:e/?eji'L
YES NO
1 . Pre Award Survey ? ?
2. OJT Agreement Template: Training dates (pg 1), reimbursement rate (pg 1), and `6Q ?
maximum reimbursement amount (pg 4), and Employer Info (pg 5) match Exhibit /-
A-Training Plan.
3. Exhibit A: Training Plan
?OJT's to employees do not exceed 1-5 ratio `? ?
SVP Level is => 3+ /
Hours of Training are reasonable
r?!,n'r`.•ost Computation is in accordance hourly wage 50% of wages or sliding scale
based on number of employees per DOL waiver.
C1?Signed by Employer
4. //Exhibit B: Assurances
5. Exhibit C: Insurance commercial/workers comp for 1,000,000 with Additional ?
Insured Endorsement naming City of Santa Ana as Additional Insured. ?
6. Exhibit D: Drug Free Workplace Form completed and signed.
7. Exhibit E: Debarment Certification signed. ? ?
8. File:
AD
S ? ?
A
urvey
EEO 8t Grievance Procedures
9. Three copies of agreement and canary routing slip attached ? ?
Comments:
C;6?? ?-?1?,1,?
Program Supervisor Date