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MGT OF AMERICA, INC. - 2013
INSURANCL Kira m t- 'avuriti MA1' al f`3rJ:ED NTIL INSURANCE RFIRES —a CLERK OF COUNCIL ©! " DATE: 10 -1`7 AGREEMENT FOR STATE MANDATED COST REIMBURSEMENT SERVICES A -2013 -154 This Agreement is effective as of the 1" day of September, 2013 by the City of Santa Ana, a municipal corporation and charter City duly organized and existing under the constitution and laws of the State of California ( "City ") and MGT of America, Inc. ( "Consultant "), a California Corporation. RECITALS A. The City desires to retain a Consultant having special skill and knowledge in the field of preparing applicable State Mandate Reimbursement claims in order to maximize revenue to City, B. The City issued a Request for Proposals for said services on July 16, 2013 (RFP 13 -035) and based upon the proposals received, this contract is being awarded to Consultant. C, Consultant represents that Consultant is an independent contractor that has the knowledge and experience to prepare and submit such State Mandate Reimbursement claims on behalf of City. D, 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: 1. SCOPE OF SERVICES Consultant shall perform those services and provide those products as set forth in Exhibit A to this Agreement. The following terms shall apply to the terms and conditions set forth in Exhibit A: 1) City shall approve each clairn; 2) Claim shall be filed based upon proof of City costs; 3) Claim shall not be filed if costs do not exceed One Thousand Dollars ($1,000) per program per year. If data needed to file applicable claims is not provided by City in a timely manner Consultant cannot guarantee timely submission of claims, Consultant will file the claims with information obtained from City, Consultant shall only file claims for which adequate records or documentation has been provided by City. 2. TERM This Agreement shall commence on the date first written above and be effective for a three (3) year period with two (2) additional one -year options to renew at the City's discretion, unless terminated earlier in accordance with Section 15, below. The term of this Agreement may be extended upon a writing executed by the Executive Director of the Finance Department and the City Attorney, 3. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, identified in Exhibit A, Consultant agrees to file all eligible annual fiscal year actual cost reimbursement claims by the due date in accordance with the annual fixed fee schedule: Claims Covered 2012 -2013 Annual & New 2013 -2014 Annual & New 2014 -2015 Annual & New Claims Due Date February 15, 2014 February 15, 2015 February 15, 2016 Annual Fixed Fee $11,500 $11,400 $11,400 b. City shall be billed quarterly for the annual fixed fee. 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. 4. INSURANCE Consultant shall obtain and maintain for the entire term of this Agreement comprehensive general liability insurance, with companies acceptable to the City, authorized to issue such insurance in the State of California. Said insurance shall consist of the following: a, 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. b. Professional Responsibility (Errors and Omissions) insurance with a combined single limit of not less than $1,000,000.00 per claim, c. rho 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 hi form by the City Attorney, (iii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspoet without thirty (30) days prior written notice to the City. 5. LIABILITY Consultant shall be responsible for performing the work pursuant to this Agreement in a professional manner and shall be responsible for the acts and omissions of its employees as related to this Agreement, Liability of Consultant to City with regard to all work and services performed or provided by Consultant for City under this Agreement shall be limited to the total fee actually paid by City to Consultant. Under no circumstances shall Consultant have any liability to City in excess of the amount of such fees or compensation, City acknowledges and agrees that but for the above limitation of liability, Consultant would not be able to provide the services for City under this Agreement for the prices applicable to this Agreement, acid that this limitation of liability is reasonable, G. WORK COMPLETION IN A TIMELY MANNER City agrees to provide information needed to complete the claims two weeks prior to the established due date or two weeks after the data has been requested by the Consultant, whichever is first. If information has been received in a timely manner, Consultant agrees to complete and file the claim(s) on or before the date established for submitting such claims to the State of California. If data is not provided in a timely manner and Consultant is unable to complete the claims, the claims shall be submitted late, when allowed by the State. City understands that late claims are subject to a 10% or One Thousand Dollar ($1,000) per claim penalty (whichever amount is less) up to one year after the original due date, City understands that the State does not allow claims to be submitted more than one year after the original due date. Consultant shall not be responsible for late penalties or for the loss of claiming opportunities. Consultant shall not be liable for any claims not filed due to incomplete, insufficient, or late information. Consultant shall be responsible for late penalties or failure to file claims if caused by mistake or negligence of its employees, officers and agents. 7. 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 an employer- employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional mamier 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. R. ASSISTANCE IF AUDITED In the event an audit is conducted by the State Controller's Office and upon notification by City, Consultant shall assist City in defending its' claim(s). 9. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health, and claims for property damage, which may arise from the negligent 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 of 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, regarding any action by a third party challenging the validity of this Agreement, or 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 arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 10. 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 care it uses to protect its own information of like importance, but in no event less than reasonable care. "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. 11. 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. 12. 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 tolefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council 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: Executive Director of Finance City of Santa Ana 20 Civic Center Plaza (M -17) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 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: MGT of America California Office: MGT of America, Inc. J. Bradley Burgess, Vice President 2001 P Street, Suite 200 Sacramento, CA 95811 Phone: 916595 -2646 bburgessCa3mgtamencom Corporate Headquarters: MGT of America, Inc. 'i1. - -Vrrtre�'l%- fe—BP 3800 ESPLANADE WAY, SUITE210 4jed4fth &S5ee_4jler4 eALLAHASSEE, FL 32311 Phone: 850 -386 -3191 Fax: 850 - 385 -4501 www.mgtofamerica.com A party may change its address by giving notice in writing to the other party, Thereafter, any 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 telefacsitnile, 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. 13. 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. 14. 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. 15. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. a. 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. 16. 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 aff ms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 17. 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 farther 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. 18. PROFESSIONAL LICE' ENSE+ S 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, 19. 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 fuully, 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. IN WITNESS WHEREOF, the parties have executed this Agreement the date and year first above written. ATTEST: MARIA D. HUIZAR .0'"—Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: 7 t✓t✓t✓ Lisa Storck Assistant City Attorney CITY OF SANTA ANA Carlos Rojas, Acting City Manager MGT of America By. Title: SENIOR PARTNER TaxlD# 59- 1576733 MGT of America Response to Iho City of Sanirl Ano w M1 Rewsst for Proposal 1;}Wp35 for Mandated Cost Claiming Services (SB 90) FXIHBIT A Within the past five years, MGT of America has not been a party to any litigation relating the work described by the City's RFP. Scope Of Service Understanding of the Project The City of Santa Ana Is a California public agency that wishes to supplement existing revenue SCUMS by filing state mandate cost claims (SI3 90 claims) with the California State Controller's Office (SCO). Uk.6 many public agencies In California, the City of Santa Ana has weathered a significant economic downturn over titre past decade. Generating sufficient revenue to offset the growing demands for service and Increased costs In many areas of government remalm a challenge, It Is our understanding that the City of Santa Ana would like to partner with a qualified consulting firm that specializes in SIB 90 consulting to do the following.' r Prepare and Elie all eligible SB90 claims for annual claims and associated ICRPs due during fiscal Year 2013.201 4 and the subsequent two Fiscal Years, 2014 -2015 and 2015 -2016. > prepare and file all eligible. S13 90 claims for all now or first -time mandates and associated ICRPs, which have claiming Instructions issued by the State Controller's office during Fiscal Year 20132014 and the subsequent two Fiscal Years, 2014.2015 and 20152016. r Assist the City with all aspects of remittance tracking Including annual claim r%elpts and claims paid reports. r Provide assistance to the City In responding to Inquiries about and /or defending claims filed by the City that are audited by the State Controller's office, r Provide guidance to the City in determining the data roquirod for claims submission atld about; new claiming opportunities including knowledge transfer and training related to the SR 90 process at the state level, �- Furnish copies of all claims filed witty the State within 30 days after the Ang and provide Coplos of working papers upon request, Following Is the MGT of America plan to accomplish your request on time and on budget. or nMtln to M1. IMF. r MGT of Ar e icCa Response ho the City of Sranici An--.a Request for Proposal 13.035 for Mandated C of C Calming Services (SB 90) i XWHIT .ltl ,annual, New and Initial Claims: Preparation and Submission r Establish schedule and approach needed to complete all annual claims due to the state by February 15, 2011. This includes on-site Interviews with all applicable City department personnel, r- Identify new claims that are expected to become mandated programs during FY 2013 -201 4, and the departments likely to be affected by these claims. As part of this step, MGT will provide early claim summaries and data collection requh•ements to provide a head start, on documentation strategies, r Work with the City, as now claiming Instructions are issued by the SCQ, to establish schedules and approaches needed to complete all new or first -time clalms due during the Fiscal Year. r� Facilitate department interviews where staff describe how the City complies with the specific mandated programs and assist the City to determine eligible costs based on the following criteria: The test claim's Statement of necislon The California Commission on State Mandates approved Parameters and Guidelines The SCCYs clahmin& instructions A How other agencies around the stato arc complying with anti interpreting the mandate r- Prepare all necessary dopartmorrt -wido ICRPs In accordance with OMB AM87, MGT consultants have prepared thousarids of ICRPs over the past 25 years. We believe that our experience has developed a depth of understanding that is unmatched in the field, r Prepare all eligible claims for die City's SB 90 programs, and review die claims for completeness, propriety, and eligibility of costs, r Perform a quality assurance review of the City's 313 90 claims to ensure that they mush with the associated department ICRPs and verify that no direct costs are double counted. )� discuss any potential or ne=cessary changes with the appropriate >. City staff member, >� Provide the completed claims and ICRPs to the City for review and signature at least three weeks prior to the claiming deadline. >~ File the signed claims with the SCCS prior to the deadline. MGT OF AMCPIC n. I,IC. 1 S � I %J' � �' li T1',i_ �h �'` ,1St* CERTIFICATE OF LIABILITY INSURANCE I ,DATE (n m'DDrm) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 PRODUCER Earl Bacon Agency, Inc. P.O. Box 12039 Tallahassee FL 32317 INSURED MGT of America, Inc. Public Resource Management Inc. 2123 Centre Point Blvd. Tallahassee FL 32308 MGTOF -1 COVERAGES CERTIFICATE NUMBER: 2063032831 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSU RANCE DLSUBR INSR VIVO POLICY NUMBER POLICY EFF MMIDDM'YY POLICY EXP flMMl LIMITS C GENERAL LIABILITY Y Y P2093390918 /1/2013 /1/2014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE K OCCUR PREMISES Eaoccurmnoa $300,000 MED EXP(My one person) $5,000 PERSONAL& ADV INJURY $1,000,000 X A -XV Rating GENERALAGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGO $2,000,000 X POLICY F7 PRO- JECT LOG $ B AUTOMOBILE LIABILITY Y Y 2093563501 /1/2013 /112014 _C_0V9=INGI_E LIMIT Ea accident ) $1,000,000 BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ • NON -OWNED HIRED AUTOS X AUTOS $ • A -XV Rating C X UMBRELLA LAS X OCCUR 2093563496 /1/2013 /1/2014 EACH OCCURRENCE $$5,000,000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED X I RETENTION $10,000 $ A D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER /EXECUTIVE F-1 OFFOEMEMBER EXCLUDED? W NIA y 3011086712 3011086788 CA /1/2013 /1/2013 /1/2014 /1/2014 X WCRSLATT- 0TH- ER CA EL -below E.L. EACH ACCIDENT $500,000 E.L. DISEASE -EA EMPLOYEE $500,000 (Mandatory in NH) If yes, describe under DE SCRIPTION OFOPERATIONS below EL .DISEASE - POLICY LIMIT $500,000 F Professional Liability(E &O) 105638880 /1/2013 /1/2014 Per Claim 2,000,000 Claims -Made Form Aggregate 3,000,000 715/95 Retro Date; A -XIV DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Umbrella: A -XV Rating. All Other Workers' Compp and CA Workers' Comp: A -XV Rating. California Employers Liability Limits: $1,000,000 Each Accident/$ 1,000,000 Disease Policy LimiV$1,000,000 Disease Each Employee. TO k C):i�.n1l � ,pptOVE � ._ lLSAmE• SIORCK e� /�� City of Santa Ana 20 Civic Center Plaza (M -30) P.O. Box 1988 Santa Ana CA 92702 -1988 ACORD 25 (2010105) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD rights NIGT of America, Inc. Pollcy#2093390918 G- 17957 -G (Ed. 01101) IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE PARAGRAPH C.7. OF THIS ENDORSEMENT FOR THESE DUTIES. ALSO, THIS ENDORSEMENT CHANGES THE CONTRACTUAL LIABILITY COVERAGE WITH RESPECTS TO THE "BODILY INJURY" OR "PROPERTY DAMAGE" ARISING OUT OF THE "PRODUCTS - COMPLETED OPERATIONS HAZARD ". SEE PARAGRAPH B.S. OF THIS ENDORSEMENT FOR THIS COVERAGE CHANGE, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTOR'S SCHEDULED AND BLANKET ADDITIONAL INSURED ENDORSEMENT WITH LIMITED PRODUCTS- COMPLETED OPERATIONS COVERAGE This endorsement modlfias insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organizatlom SCHEDULE Designated Project: (Coverage under this endorsement Is not affected by an entry or lack of entry In the Schedule above.) A. WHO IS AN INSURED (Section II) is amended to 2. The Limits of Insurance applicable to the include as an Insured any parson or organization, additional Insured are those specified In the including any person or organization shown In the written contract or written agreement or In the E 5 schedule above, (called additional insured) whom you Declarations of this policy, whichever Is less, are required to add as an additional insured on this These Limits of Insurance are inclusive of, and not policy under a written contract or written agroement; In addition to, the Limits of Insurance shown in the but the written contract orwriifteen agreement must be: Declarations. 1, Currently In effector becoming effective during the 3. The coverage provided to the additional insured term of thin policy; and by this endorsement and paragraph f. of the 3= 2. Executed prior to the 'bodily Injury," "property definition of 'insured contract' "under OEFINITIONS (Section V) do not apply to bodily damage,' or "personal andadvart sing injunj . fnjury" or "property damage" arising out of the S. The insurance provided to the additional insured is "products - completed operations hazard' unless 5 limited asfollows: required by the written contract or written When coverage does to "bodily agreement apply 1. That a son or o anizat on is an additional onjury or "property damage" arising out of the insured soles for liablii due to our negligence � y n y products - completed operatbris hazard" such ,a specifically resulting from "your work" for the coverage will not apply beyond: additional insured which Is the subject of the written contract or written agreement No a. The period of time required by the written coverage applies to tiahliity resulting from the sole contractor written agreemenl; or negligence of the additional insured. 0- 17957 -G A1'i >i3f�iFL AS "T Yr�'s 1V3 Page 1 of 2 (Ed. 01101) F \ssistant City A.; Orney 1I b. 5 years from the completion or "your work' on the project which is the subject of the written contractor written agreement, whichever is less, 4. The insurance provided to the additional insured does not apply to "budily Injury," "property damage," or `personal and advertising Injury" arising out of an architect's, engineer's, or surveyors rendering of or faflure to render any professional services including a. The preparing, approving, orfelling to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and A. Supervisory, or Inspection activities performed as part of any related architectural or engineering activities. C. As respects the coverage provided under this endorsement, SECTION iY — COMMERCIAL. GENERAL LIABILITY CONDITIONS are amended as fcitows: 1. The following Is added to the Duties In The Event of Occurrence, Offense, CEaim or Suit Condition: A. An additional insured under this endorsement will as soon as practfoat4a: G- 17957 -G (Ed. 01101) G- 17957 -r3 (Ed. 01/01) (1) Give written notice of an occurrence or an offense to us which may result In a claim ar "suit" under this insurance; (2) Tender the defense and Indemnity of any claim or "cull' to any other insurer which also Ices insurance for a loss we cover under this Coverage Park and t3) Agree to make available any other Insurance which the additional insured has for a loss we cover under this Coverage Part, f. We have no duty to defend or indemnify an additional Insured under Us endorsement until we receive written notice of a claim or "sari" from the additional Insured. 2. Paragraph 4,1J, of the Other Insurance Condition is deleted and replaced with the following: 4. Other Insurance b. Excasslnsyrdnca This insurance Is excess over any other insurance naming the addrilonal insured as an Ensured whefher primary, excess, oontingent or on any other basis unless a written contract or written agreement specifically requires that this Insi rence be either primary or primary and nonconidbuting. 'TO ����jPage 2of2 `"- ')RCK grsistarnt Citl„Attorna >,V rem s� MGT of America, Inc. Po]]cy 3011086712 All Other WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4 -134) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our right against the person or crganizatlen named In the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agisemontshall not oparate'directly or Indirectly to banelll anyone not named in the Schedule. Schedule ANY PERSON OR ORGAbaZATSON ON WHOSE BEHALF YOU ARE REQUIRED TO OBTAIN THIS WAIVER OF OUR RTGRT TO RECOVER FROM UNDER A WRITTEN CONTRACT OR AGREEMENT. This endoraomont changes tho policy to whleh n Is attschod and Is e11e011VO an the date Issued unless othendeo asated. (The infarmallch below Is required only what this Onderaemanl Is bsuOd subesquent to preparetlon of the pollcy.l Endorsement Effeclris Palley No. Endor60mehtNo, Insured Prendums Insurance Oompany WC 00 OS 13 (Ed,"4) Countersigned by Copyright 11693 Nedonet COMM un OompensaUon Insurance. D 1�6 LISA � " ` Attorney p„sistant City MGT of America, Inc Policy 8011086788 • GA lZi 1:1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE- POLICY 01LANKGT A men OF Oun niQHT To RI_coyaR FRom OTHERS This endorsement changes the policy to which It Is attached, G -11916" (Ed. I IM7) It is agread that Part One Workera' Compensation Insurance Q. Recovery From Others and Part Two Employers' Liabliiiy Imuranos H. Recovery From Others are amended by adding the following; We will not enforce our right to recover against persons or organizations. (This agreement applies only to the extent that you perform work under a written contmcithat requires you to obtain this agreement from us.) PREMIUM CHARGE - The charge will be an amount to which you and we agree that Is a percentage of the total standard premium for California exposure, The amount Is G- 19160 -8 (Ed, 1 1157) �vt"`S. ✓ °„ ° t �atv N loll A.,sistrri� AUTOMOBILE ADDITIONAL INSURED & WAIVER OF SUBROGATION 1. Who Is An Insured The following are "insureds ": a. You for any covered "auto ", b. Anyone else while using with your permission a covered "auto" you own, hire or borrow except: (1) The owner or anyone else from whom you hire or borrow a covered "auto ". This exception does not apply if the covered "auto" is a "trailer" connected to a covered "auto" you own. (2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her household. (3) Someone using a covered "auto" while he or she is working in a business of selling, servicing, repairing, parking or storing "autos" unless that business is yours. (4) Anyone other than your "employees ", partners (if you me a partnership), members (if you are a limited liability company), or a lessee or borrower or any of their "employees ", while moving property to or from a covered "auto ". (5) A partner (if you are a partnership), or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household. c. Anyone liable for the conduct of an "insured" described above but only to the extent of that liability. Provides "additional insured" status 5. Transfer Of Rights Of Recovery Against Others To Us If any person or organization to or for whom we make payment under this Coverage Fonn has riglhts to recover damages from another, those rights are transferred to us, That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them. Policy automatically permits "waiver of subrogation E �fURCK LISA City Attor neY Assistant , 1/I e l Business Auto Policy MGT of America, Inc. Policy 2093563501 13, Owned Autos You Acquire After The Policy 'covered pollution cost or expense.' However, we Begins have no duty to defend any 'insured' against a'sult' t. if Symbols 1, 2, 3, 5, 6 or 19 are entered next seeking damages for 'bodily injury' or 'Property a to a coverage In Item Two of the Declarations, damage' or a'covered pollution cost or expense" to than you have coverage for 'autos' that you which this insurance does not apply. We may acquire of the type described for the remainder investigate and settle any claim or 'suit' as we of the policy period, consider appropriate. Our duty to defend or settle 2. taut, 11 Symbol 7 is entered next to a coverage in ands when the Liability Coverage Limit of Insurance has been exhausted by payment of judgments or Item Two of the Declarations, an 'auto' you settlements, acquire will be a covered 'auto' for that coverage only 'd: 1, t In An Insured a. We already cover all 'autos' that you own The following are lnsureds': for that coverage or it replacss an 'auto' a. You for any covered 'auto " You Previously owned that had that coverage; and b. Anyone else while using with your b. You tell us within 30 days after you acquire permission a covered 'auto' you own, hire or borrow except: it that you want us to cover it for that (1) The owner or anyone also from whom coverage, you hire or borrow a covered 'auto.' C. Certain Trailers, Mobile Equipment And This exception does not apply if the Temporary Substitute Autos covered 'auto' is a 'trailer' connected If Liability Coverage is provided by this Coverage to a covered 'auto' you own. Form, the following types of vehicles are also (2) Your'employse' if the covered 'auto* is covered 'autos* for liability Coverage; owned by that -employee' or a member 1. 'Trailers' with a load capacity of 2,000 pounds of his or her household, or less designed primarily for travel on public (3) Someone using a covered 'auto' while roads, he or she is working in a business of 2. 'Mobile equipment' while being carried or towed selling, servicing, repairing, parking or by a covered 'auto.' storing 'autos' unless that business is 8. Any 'auto' you do not awn while used with the yours. o permission of its owner as a temporary (4) Anyone other than your 'amployess,' substitute for a covered 'auto' you own that is Partners (if you are a partnership), out of service because of its; members (If you are a limited liability a. Breakdown; company), or a lessee or borrower or 'employees,' any of their while moving b. Repair•, property to or from a Covered 'auto.' c, Servicing; (S) A partner (it you are a partnership), or d. 'Loss'; or a member (if you are a limited liability a, Destruction. company) for a covered 'auto' owned by him or her or a member of his or her SECTION 0 — LIABILITY COVERAGE household. A. Coverage c. Anyone liable for the conduct of an We will pay all sums an 'insured' legally N pay el must a 'insured' described above but only to the extent of that Ilabllity. as damages because of 'bodily injury' or 'properly damage' to which this insurance applies, caused by 'accident' 2, Covers g a Extenaiorts an and resulting from the ownership, a. Supplementary Payments maintenance or use of a covered auto.' We will pay for the 'insured': We will also pay all sums an 'insured' legally must 'covered (1) All expenses we incur. pay as a pollution cost or expense' to which this insurance applies, caused by an (2) Up 10 $2,000 for cost of ball bonds 'accident' and resulting from the ownership, (including bonds for related traffic law maintenance or use of covered 'autos.' However, violations) required because of an WA will only pay for the 'covered pollution cost or accident' we cover. we do not have to expense' if there Is either 'bodily injury' or 'property furnish these bands. damaga' to which this Insurance applies that is 'accident." (3) The cost of bonds to release caused by the same attachments in any 'suit' against the We have the right and duty to defend any "Insured' 'insured' we defend, but only for bond against a 'suit' asking for such damages or a amounts within our Limit of Insurance. P4ge2 of 11 Co APPROVED S Copyright, ISO Properties, Inc„ 2005CArpO 67 g3 tl6 LISA E, Sl ORCK...__ J �9ictent co', Attorney �� Business Auto Policy MGT of America, Inc. Policy 2043563501 SECTION IV — BUSINESS AUTO CONDITIONS The following conditions apply in addition to the Common Policy Conditions: A. Lose Conditions 1. Appraisal For Physical Damage Loss If you and we disagree on the amount of 'loss,' either may demand an appraisal of the loss,' In this event, each party will select a competent appraiser. The two appraisers will select a competent and impartial umpire. The appraisers will stale separately the actual cash value and amount of loss.' If they fall to agree, they will submit their differences to the umpire, A decision agreed to by any two will be binding. Each party will: a. Pay its chosen appraiser; and b. Bear the other expenses of the appraisal and umpire equally. If we submit to an appraisal, we will still retain our right to deny the claim. 2. Duties In The Event Of Accident, Claim, Suit Or Loss We have no duly to provide coverage under this policy unless there has been full compliance with the following duties: CA 00 0103 06 (1) Promptly notify the police it the covered 'auto' or any of its equipment Is stolen. (2) Take all reasonable slaps to protect the covered 'auto' from further damage. Also keep a record of your expenses for consideration in the settlement of the claim. (3) Permit us to inspect the covered 'auto' and records proving the 'loss' before Its repair or disposlllon. (4) Agree to examinations under oath at our request and give us a signed statement of your answers. 3. Legal Action Against Us No one may bring a legal action against us under this Coverage Form until: a. There has been full compliance with all the terms of this Coverage Form; and b. Under Liability Coverage, we agree in writing that the 'insured' has an obligation to pay or until the amount of that obligation has finally been determined by judgment after trial. No one has the right under Ihfs Policy to bring us into an action to determine the 'Insureds' liability. 4. Loss Payment — Physical Damage Coverages At our option we may: a. Pay for, repair or replace damaged or stolen property: b. Return the stolen property, at our expense, We will pay for any damage that results to the 'auto' from the thaft; or o. Take all or any part of the damaged or stolen property at an agreed or appraised value. It we pay for the 'loss; our payment will include the applicable sales tax for the damaged or stolen property. S. Transfer Of Rights Of Recovery Against Others To Us It any person or organization to or for whom we make payment under this Coverage Form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident' or 'loss' to impafrthom. B. Caneral Conditions 1. Bankruptcy Bankruptcy or insolvency of the 'insured' or the lnsured's' estate will not relieve us of any obligations under this Coverage Form. 2. Cone" nant, MisroP lesentatfon Or Fraud This Coverage Form is void in any case of fraud by you at aiffj)t �ft ,thls Colgrage Copyright, ISO Properties, Inc., 2005 Page 7of 11 LiSA C, Si ORCK Assistant City Attorney l �� D. In the event of 'accident,' claim, 'suit' or loss,' you must give us or our authorized representative prompt notice of the 'accident' or 'loss,' Include; (1) How, when and where the 'accident' or 'loss' occurred; (2) The Insured's' name and address; and (3) To the extant possible, the names and addresses of any injured persons and witnesses. b. Additionally, you and any other involved 'insured' must: (1) Assume no obligation, make no Payment ar incur no expense without our consent, except at the 'insured's' own cost. (2) Immediately send us copies of any request, demand, order, notice, summons or legal paper received concerning the claim or 'suit.' (3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit.' (4) Authorize us to obtain medical records or other pertinent information. (6) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably require. C. It there is 'loss- to a covered 'auto' or its equipment you must also do the following: CA 00 0103 06 (1) Promptly notify the police it the covered 'auto' or any of its equipment Is stolen. (2) Take all reasonable slaps to protect the covered 'auto' from further damage. Also keep a record of your expenses for consideration in the settlement of the claim. (3) Permit us to inspect the covered 'auto' and records proving the 'loss' before Its repair or disposlllon. (4) Agree to examinations under oath at our request and give us a signed statement of your answers. 3. Legal Action Against Us No one may bring a legal action against us under this Coverage Form until: a. There has been full compliance with all the terms of this Coverage Form; and b. Under Liability Coverage, we agree in writing that the 'insured' has an obligation to pay or until the amount of that obligation has finally been determined by judgment after trial. No one has the right under Ihfs Policy to bring us into an action to determine the 'Insureds' liability. 4. Loss Payment — Physical Damage Coverages At our option we may: a. Pay for, repair or replace damaged or stolen property: b. Return the stolen property, at our expense, We will pay for any damage that results to the 'auto' from the thaft; or o. Take all or any part of the damaged or stolen property at an agreed or appraised value. It we pay for the 'loss; our payment will include the applicable sales tax for the damaged or stolen property. S. Transfer Of Rights Of Recovery Against Others To Us It any person or organization to or for whom we make payment under this Coverage Form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident' or 'loss' to impafrthom. B. Caneral Conditions 1. Bankruptcy Bankruptcy or insolvency of the 'insured' or the lnsured's' estate will not relieve us of any obligations under this Coverage Form. 2. Cone" nant, MisroP lesentatfon Or Fraud This Coverage Form is void in any case of fraud by you at aiffj)t �ft ,thls Colgrage Copyright, ISO Properties, Inc., 2005 Page 7of 11 LiSA C, Si ORCK Assistant City Attorney l �� Moog i POLICY NUMBER: 2093390918 COMMERCIAL GENERAL LIABILITY CG 24 04 0S o9 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 1`19iI401114:� Name Of Person Or Organization: Refer to SCHEDULE CG2404 this The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or 'your work' done under a contract with that person or organization and included In the 'products- completod oparations hazard.' This waiver applies only to the person or organization shown in the Schedule above. Assistant City Attni nm, CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 I I G/ Page 1 of 1 Package Policy with Property Insight Endorsement Declaration POLICY NUMBER COVERAGE PROVIDED BY P 2093390918 CONTINENTAL CASUALTY COMPANY 333 S. WABASH CHICAGO, IL. 60604 INSURED RAMS AND ADDRESS MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 AGENCY NUMBER AGENCY MAKE AND ADDRESS 033069 EARL BACON AGENCY, INC. 3131 LONNBLADH ROAD PO BOX 12039 (32317) TALLAHASSEE, FL 32308 Phone Number: (850)878 -2121 BRANCH NUMBER BRAMCB MANX AND ADDRESS 770 FLORIDA BRANCH 2405 LUCIEN WAY P.O. BOX 946500 o MAITLAND, FL 32794 Phone Number: (407)919 -3000 s r s S it CNA FROM - POLICY PERIOD - TO 07101/2013 07/01/2014 This endorsement changes your policy. Please read it carefully. This endorsement results in no change in premium. LISA E. SC0;21 K Assistant City Attorney INSURED Page 1 of 2 POLICY NUMBER INSURED NAME AND ADDRESS P 2093390918 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 FORMS AND ENDORSEMENTS SCHEDULE These following forms have been added to your policy Form Humber Form Title G56015B 11/1991 ENDORSEMENT EFFECTIVE 8/20/13 Countersignature Px CnWw of S=4 Cat`,' Attorn <" AslstanA/ I/ k P- 55170 -A (Ed. 01/86) INSURED lU Page 2 of 2 POLICY NUMBER INSURED NAME AND ADDRESS P 2093390918 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 POLICY CRANGES ENDORSEINT EFFECTIVE 0 /20/13 This Change Endorsement changes the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes offset on the affective date of your Policy, unless another effective date in shown. G- 15115 -A (Ed. 10/89) This form has been added to the policy: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGES - NOTICE OF CANCELLATION OR MATERIAL COVERAGE CHANGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage Part (other than S the reduction of aggregate limits through payment of claims), we agree to mail prior written notice of cancellation or material change to: SCHEDULE 1. Number of days advance notice: 30 30 Days for Non - Payment of Premium City of Bakersfield, Finance Department - City Hall North 1600 Truxton Avenue Bakersfield, CA 93301 City of Fort Bragg 416 N. Franklin Street Fort Bragg, CA 95437 City of LaMirada 13700 LaMirada Blvd LaMirada, CA 90638 Cn.lrm�n a We Bw d G- 56015 -B (ED. 11/91) 10 40 r�ppff)- " LISA t° )% Attorney C`t sereun POLICY NUMHSR IN99MED NAM AND ADDR888 P 2093390918 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 POLICY CRANO88 BNDORBBI[8NT $PFSCTIVR 8/20/13 This Change zndorsemmt changes the Policy. Please read it carefully. This Change 8ndorseaent is a Part of your Policy and takes effect on the effective date of your Policy, unless another effective data is shrnm. 'City of Santa Ana - 20 Civic Enter Plaza (M -30) P.O. Box 1988 Santa Ana, CA 92702 -1988 City of Sunnyvale, Purchasing Division 650 West Olive Ave. P.O. Box 3707 Sunnyvale, CA 94088 -3707 City of TurlocK, CA 156 South Broadway, Suite 110 Turlock, CA 95380 -5454 Lake County Purchasing Division 18 North County Street Waukegan, Illinois 60805 -4350 11 s cn. "nameHood G- 56015 -B (£D. 11/91) PIS 5 JRi (� ey 4-J+^- CNA Business Auto Hndorsement Declaration POLICY NVMHER COVERAGE PROVIDED BY FROM - POLICY PERIOD - TO P 2093563501 AMERICAN CASUALTY CO OF READING,PA 07/0112013 07/01/2014 333 S. WABASH CHICAGO, IL. 60604 INSURED NAME AND ADDRESS MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 AGENCY NUMBER AGENCY NAME AND ADDRESS 033069 EARL BACON AGENCY, INC. 3131 LONNBLADH ROAD PO BOX 12039 (32317) TALLAHASSEE, FL 32308 Phone Number: (850)878 -2121 BRANCH NUMBER BRANCH MAKE AND ADDRESS 770 FLORIDA BRANCH 2405 LUCIEN WAY P.D. BOX 946500 MAITLAND, FL 32794 Phone Number: (407)919 -3000 This endorsement changes your policy. Please read it carefully. This endorsement results in no change in premium. Audit Period is Not Auditable ii :G 110 INSURED Hssistant City Page 1 of 2 8OLICY NUMBER INBDRED NAME AND ADDRESS P 2093563501 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 FORMS AND SNDORSEKRNTS SCHEDULE The following forms have been added to this policy. FORM NOMBER FORK TITLE G56015B 11/1991 ENDORSEMENT EFFECTIVE 8/20/13 1 "' M wc4 — chkfto am. surd P- 55748 -B (Ed. 12/90) Countersignature 11 FC�I�I 'p, RtioY nay F ssis'kant �It) INBtIR 5I V V) U Mly Page 2 of 2 POLICY NUMBER INSURED NAME AND ADDRESS P 2093563501 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 POLICY CHANGES ENDORSEMENT EFFECTIVE S/20/13 This Change Endorsement changes the Policy. Please road it carefully. This Change Endorsement is a Part of your Policy and takes affect on the effective date of your Policy, unless another effective date is Shona. G- 140327 -B (Ed. 07/11) This form has been added to the policy: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION BY US NOTICE TO DESIGNATED PERSONS This endorsement modifies insurance provided under the following: THE COMMON POLICY CONDITIONS OF THE BUSINESS AUTO COVERAGE FORM The following is added to Paragraph A. CANCELLATION: A. 7. In the event we cancel your policy in accordance with your policy's terms and conditions, we will mail written notice of cancellation to the designated persons named below within the stated time frames. a. 10 days before the effective date of cancellation if we cancel for non - payment of premium, or b. 30 days before the effective date of cancellation if we cancel for any other reason. Designated Person(s) 1.City of Bakersfield, Finance Department 2.City of Fort Bragg 3.City of LaMirada 1� .City of Santa Ana 5.City of TurlocK, CA NEW Chk"n of BM Bond G- 56015 -B (ED. 11/91) Address City Hall North 1600 Truxton Avenue Bakersfield, CA 93301 416 N. Franklin Street Fort Bragg, CA 95437 13700 LaMirada Blvd LaMirada, CA 90638 20 Civic Enter Plaza (M 30) P.O. Box 1988 Santa Ana, CA 92702 -1988 156 South Broadway, Suite 110 Turlock, CA 95360 -5454 , V0 Jl ORC s« wiry f �AGSisVtant Clty Attorney POLICY NMEBER INSURED NAME AND ADDRBGS P 2093563501 MGT OF AMERICA, INC. 2123 CENTRE POINT BLVD TALLAHASSEE, FL 32308 -4930 POLICY CHMONS ENDORBEIMT E!Y'ECrx" 0/20/13 This Change Endorsement changes the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes effect on the effective date of your Policy, unless another effective date Is shown. 6.Lake County Purchasing Division 7.Siskiyou County, Auditor's Office Em M 10. i i• SEEN i Chakm of the BWd G- 56015 -8 (ED. 11/91) 18 North County Street Waukegan, Illinois 600805 -4350 311 Fourth St., RM 101 Yreka, CA 96097 9ecretery — VA F. 3 10FtCKJ. Assistant. City AtforneY s--p/1j Ir'r 0- 20472 -A CNN (Ed. 10193) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY NOTICE OF CANCELLATION OR MATERIAL CHANGE ENDORSEMENT In the event of cancellation or other material change of the policy, we will mail advance notice to the person or organization named in the Schedule. The number of days advance nodes is shown in the Schedule. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule 1. Number of days advance notice: 30 2, Notice will be mailed to: CITY OF LAMIRADA 13700 LAMIRADA BLVD LAMIRADA, CA 90638 'C'ITY OF SANTA AMA - V-'20 CIVIC ENTER PLAZA {M -30} P.O. BOX 1988 SANTA ANA, CA 9270221988 G- 24472 -A Page 1 of 1 (Ed. 10193) {jst;K LISa GitY`�io } CERTIFICATE. OF LIABILITY INSURANCE DATE (MMiQDf'YYYYI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must, be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER Earl Bacon Agency, Inc. P.O, Box 12039 Tallahassee FL 32317 CONTACT NAME: _. l�. a..fa.c..y_..L�,,.I.ta.-ch.e�.L o ...... PHONE PAX 1.2 No. E Arc No . E -MAID INSURER S' AFFORDING COVERAGE NAIC # Y INSURER.Ar.: _I'aWortatlon Ins Company 5095130327 /112014 INSURED M:GTOF -1 ..._.__ INSURER B :Am ri. n .C:Q,.Qf .F..d.it,, PA $1,000,000 MGT of America, Inc. Public Resource Management Inc. 3800 Esplanade Way,Ste 210 Tallahassee FL 32311 ry ((?? 2 G16 � a ,Sq INSURER C : _Q Ltt(I1IaLCsualty Company 120443 INSURER D:VQIley Forge Insurance Co. INSURER E :Tr v I rC 1 s. r m . fA l: a1194 INSURER - $300,000 COVERAGES CERTIFICATE NUMBER: 808488960 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR LTR TYPE OF INSURANCE ADDL INSR. UBR WVD �. -. POLICY NUMBER lMM1D6IYYYY MM DDIYYYY LIMITS A GENERAL LIABILITY Y Y 5095130327 /112014 1112015 EACH OCCURRENCE $1,000,000 x CLAIMS -MADE FX � OCCUR EAMAGE T EO PiEMISES La occurrence - $300,000 MED EXP {Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 X A -XV Rating ._.._._....._....... ._ _._. GENERAL AGGREGATE $2 „000.000 PRODUCTS - COMPIOP AGG . $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ _..� X PRO- POLICY LOC B AUTOMOBILE LIABILITY Y Y 2093563501 1112014 /112015 COMB ED SIN(iLF LIMIT _ jEa accudent'I 1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X NON - OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE ..,(Per accident . $ $ X..__ A -XV Rating C x UMBRELLA LIAR x OCCUR 2093563496 1112014 /112015 EACH OCCURRENCE $$5,000,000 AGGREGATE $$5,000,000 EXCESS LIAR CLAIMS -MADE DED x RETENTION$ 10,000 . �$ D A WORKERS COMPENSATION ANQEMPLOYERS' LIABJLITY YIN Y 3011086712 -AII Other 3011086788 CA /112014 /112014 1112015 11 /2015 x TWO STATU- OTH- I I.. CA EL -below E.L. EACH ACCIDENT $500,000 ANY PROPRIETORIPARTNERIExECUTIVE D OFFICEWMEMBER EXCLUDED? NIA '... E.L. DISEASE • EA EMPLOYE $500,000 (Mandatory in NHS If yS describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $500.,.000 Professional Liabitity(E &O) Claims -Made Form 105638880 106080925-Cyber Liab. 1112014 /112014 71112015 /112015 Per Claim 2,000,000 Aggregate 3,000,000 7/5195 Retro Date; A -XIV Cyber Liab. 1,000,000 DESCRIPTION'.. OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) !Umbrella: A -XV Rating. All Other Workers” Comp and CA Workers' Comp: A -XV Rating. California Employers Liability Limits: $1,000,000 Each Accident/$1,000,000 Disease Policy Limit/$1,000,000 Disease Each Employee. CERTIFICATE HOLDER CANCELLATION City of Santa Ana 20 Civic Center Plaza (M -30) P.O. Box 1988 Santa Ana CA 92702 -1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE, THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORDl „y(I'( (� I/2 -r.7 arWi b Blank Page lA &q, s, w did 0 CA Policy 5095130327 G- 17957 -G (Ed. 01/01) IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. 'SEE PARAGRAPH C.1. OF THIS ENDORSEMENT FOR THESE DUTIES. ALSO, THIS ENDORSEMENT CHANGES THE CONTRACTUAL LIABILITY COVERAGE WITH RESPECTS TO THE "BODILY INJURY" OR "PROPERTY DAMAGE" ARISING OUT OF THE "PRODUCTS - COMPLETED OPERATIONS HAZARD ". SEE PARAGRAPH B.3. OF THIS ENDORSEMENT FOR THIS COVERAGE CHANGE, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTOR'S SCHEDULED AND BLANKET ADDITIONAL INSURED ENDORSEMENT WITH LIMITED PRODUCTS - COMPLETED OPERATIONS w This endorsement modifies insurance provided under the following:. COMMERCIAL GE NERAL LIABILITY COVERAGE PART Name of Pwam or OMmization: N SCHEDULE [1 • , ... _ w (Coverage undw V* eiWamnerd is rwt NI'rrctad by an entry or tack of entry In the Schedule above.) A. WHO IS AW INSURED (Section 19 is amended to 2, The Limits of Insurance applicable to the include as an insured any person or organization,' additional insured are those specified In the including any person or organization shown in the written contract or written agreement or In the schedule above, (called .additional insured) whom you Declarations of this policy, whichever is less. are required to acid as an additional insured on this These Limits of Insurance are inclusive of, and not policy under a written contract or written agreement,; in addition to, the Limits of Insurance shown in the but the written contract or written agreement must be: Ceclarations. 19M 1. Currently in effect or becoming effective during the 3. The coverage provided to the additional insured term of this polio; and by this endorsement and paragraph f, of the 2. Executed prior to the 'bodily injury,' "property definition of "insured contract" under DEFINITIONS (Section V) do not apply to bodily DEFINITIONS damage," or "personal and advertising injury. or "property damage" arising out of the MOM 9. The Insurance provided to the additional insured is "products -o mpteted operations hazard" unless limited as follows: required by the written contract or written agreement. When coverage does apply to "bodily 1- That rson or organization Is an additonaf f injury or "property damage' arising out of the insured solely for liability due to your negligence "produce- completed operations hazarcr such specifically resulting from "your work* for the coverage will not apply beyond: additional insured which Is the subject of the written contract or written agreement. No a. The period of time required by the written coverage applies to liability resulting from the sole contract or written agreement; or negilgerm of the additional insured G-1 7957-G � rage t of 2 trj --,. 1,zc) Blank Page to,,,,w, 6�y b. 5 years from the completion of *your work' on the project which is the subject of the written contract or written agreement, whichever is less. 4. The insurance provided to the additional insured does not apply to *bodkiy injury,' *property damage,' or *personal and advertising injury' arising out of an architect's, engineer's, or surveyor's rendering of or failure to render any professional services including: a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, Meld orders, change orders or drawings and specifications; and b. Supervisory, or inspection activities performed as part of any related architectural or engineering activities. C. As respects the coverage provided under this endorsement, SECTION Iv — COMMERCIAL GENERAL LIABILITY CONDITIONS are amended as follows: 1. The following is added to the Dubes In The Event of Occurrence, Offense, Claim or Suit Condition: •. An additional insured under this endorsement will as soon as practicable, G- 17957-G (Ed. 01/01) G -1 7957 -G (Ed, 01/01) (1) Give wTitien notice of an occurrence or an offense to us which may result in a claim or *suit" under this insurance; (2) Tender the defense and Indemnity of any claim or *suit' to any other insurer which also has insurance for a loss we cover under this Coverage Part; and (3) Agree to make insurance which has for a loss Coverage Part. available any other the additional insured we cover under this f. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a claim or *suit" from the additional Insured'. 2. Paragraph 4.b. of the father Insurance Condition is deleted and replaced with the following: 1 i w b. Exms km rmm This insurance is excess over any other insurance naming the additional insured as an insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance be either primary or primary and noncontributing. is" �JJ'za n -Iu " Blank Page Wo MGT of America, Inc. Policy 3011086712 All Oth ®r WORKERS COMPENSATION AND EMPLOYERS LLABIL17Y INSURANCE POLICY WC 00 03 13 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone Ilable for an Injury covered by this policy, We will not 9nforoo our right against the person or oiganizailon named In the Schedule. (This agreement applies only to the extent that you perform work under a written aonirad that requires you to obtain )hie agreement from us.) This agrearnentshall not operate'dfreottyorindbreotiy to benefit anyone not named fn the Schedule. Schedule ANY PERSON OR OR=N:r%ATION ON WHOSE BEMW YOU FIRE REQUIRIM TO OBTAIN THIS WAIVER OF OUR RIGHT TO RECOVER FROM UNDER A WRXTTEN CONTRACT OR AGREEMIT . C 4 i i 1 This ondorserriRd oba Wo 1ha policy to vtdch ft Is attach9d and is etlocllve on the dmte InwId unto,$ olherwhe etatad. (Ttse Inlarmatton bolow IN requlrod on6y vh an Ilrra andommonl is k9W 6ubWU8?11 to pmpmkn of the policy.) 00 Ea*s era 9nI Eltactf a F oOw No. tx�daraanlcartlVo: lnaurad Pramium $ I[murarroe Com x � A Oaunim 4gnad by JC iJL we 0009 is (Ed. 44 4) Capydght 1989 Ndonal counclt on Compeneaticn Imuranoe. 6� ai'& " C)L)MIK +I ZO Blank Page f/ 2,0 G-191 60-B CNA (Ed. 11197) CA— Policy 301186788 WORKERV COMPENSATION AND EMPLOYERS' UABILrTY INSURANCE POLICY BLANKIET WAP4115A OF OUR RIGHT TO RECOVER FROM OTHERS This endorsement changes the policy to which it is attached, It Is agreed that Part One Workers'Comperawtion Inamence G. Recovery From O"W* and Part Two Employers' Lk WIlty 10mmanee H. Recovery From 00wa are amended by adding the following: We will not enforce our right to recover against persons or organizations. (This agreement applies only to the Went that you perform work under a written contract that requires you to obtain this agreement from us,) PREMIUM CHARGE- $9 The charge will be an amount to which you and we agree that is a percentage of the total standard premium for Calidomia exposure. The amount is -%. G-19160-6 Page I of 1 (Ed. 11/97) Blank Page AUTOMOBILE ADDITIONAL INSUREJ) & WAIVER OF SUBROGATION I- W1►0 Is An Insured The following are "insureds": a, You for any covered "auto". b. Anyone else w1►ile, using with your permission a covered "auto "' you own, hire or borrow except: (1) The owner or anyone else from whom you hire or borrow' a covered "auto", This exception dots not apply if the covered "auto" is a "trailer" connected to a covered "auto,, you own. (2) Your "employee' if the covered "auto" is owned by that "employee, Or a member of his or her household. (3) Someone using a covered "auto" while he or she is working in a business of Selling, servicing, repairing, parking or storing "autos" unless that business is yours. (4) Anyone other (han your "employees,,, partners (if you are a partnership), members (if you are a limited liability company), or a lessee or borrower or any of their "employe&', while moving property to or from a covered "auto". (5) A partner (if you are a partnership), or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household. c. Atiyono liable for the conduct of an "insured" described above but onIy to the extent of that liability, Provides "additional insured" status 5. Tiransfer Of Riglits Of Recovery Against Others To Us If MY person or organization to or for whom we make payment under this Coverage Form has rights to recover damages firOln another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them. Policy automatically �pern-2jts "waiver �f su� tion waiver ofsubrop-ation, i,040--h 6w^,w, il i 2..0 Blank Page I x/40 Business Auto policy MGT of America, Inc. Policy 2093563501 13. Owned ALdos You Acquire After 'the Policy 'covered Pollution cost or expense.' However, we Begins have no duty to defend any 'insured' against a *suit, i. If Sy mbol$ 1, 2, 3, 4, 5, 6 or 19 era entered next seeking damages for 'bodily Injury' or 'property to a coverage in Item Two of the Declarations, da' mage or a covered pollution cost or Gxpensa4 to then you have coverage tot autos' that you which this insurance does not apply. We may acquire of the type described for the remainder investigate and sale any claim or 'suit' as we of the policy period. consider appropriate. Our duty to defend or seft 2. But, 11 Symbol' 7 is entered next to a coverage in ends when the Liability Coverage Limit of Insurance has boon exhausted by payment of judgments or Item Two of the Declarations, an :auto* you settlements, acquire will be a covered auto for that coverage only if; 1. Who Is An In mrod a. We already cover all 'autos' that you own The following are 'Insureds': for that coverage or It replaces an "auto' a. You for any covered auto., YOU Pt8l owned that had that coverage; and b. Anyone else while using with your b. You tell us within 30 days after you acquire Permission a covered waUlo' you own, hire or borrow excel it that you want us to cover it for that (1) The owner or anyone also from whom coverage, C. Certain Trailers, Mobile Equipment Airid you hire or borrow a covered "auto." This exception does not apply if the Temporary Substitute Autos covered 'auto' Is a 'trailer" connected If Liability Coverage Is provided by this Coverage to a covered 'auto' you own. Form, the following types of vehicles are also (2) Your 'Ornilloyse' if the covered 'auto* is covered 'autos' for Liability Coverage: owned by that "employee' or a member I. 'Trailers' wish a load capacity of 2,000 of his or her household. pounds or less designed primarily for travel: on public (3) Someone using a covered 'auto' while roads, he or she is working in a business of 2, 'Moblle equipment* while being carried or towed selling, servicing, repairing, parking or by a covered 'auto., storing "autos' Unless that business is 3. Any 'auto' you do not own while used with the yours. permission of its owner as a temporary (4 ) Anyone other than your 'employees,' substitute for a covered 'auto' you own that is partners (if you are a partnershlp), out of service because of its, members (11 you are a limited liability a. Breakdown; company), or a lessee or borrower or 'employees,' any of their while moving b. Repair; property to or from a covered 'auto,* a. Servicing; (5) A partner (if you are a partnership), d. 'Loss-, or or a member (if you are a limited liability e. Destruction. company) for a covered 'auto' owned by him or her or a member of his or hat SECTION ill — LIABILITY' COVERAGE household. A. Coverage c. Anyone liable for the conduct of an We will pay all sums an 'insured' legally must pay 'Insured' described above but only to the as damages because of *bodily injury' or 'Property extent of that liability. damage" to which this insurance applies, caused by 'accident' 2• Coverage Exterrsioris an and resulting from the ownership, maintenance or use of a covered 'l a. Supplamemary Payments We will RISO Pay all sums an "insured, legally must We Will pay tot the 'Insured': Pay as a 'covered pollution cost or expense" to expenses (1) All expenses we incur. which this insurance applies, caused by an (2) Up to $2,000 for cost of ball bonds .accident' and resulting from the ownership, (including bonds for related traffic law maintenance or use of covered 'autos." However, violations) required because of an we will only pay for the 'Coveted pollution cost or accident' we cover. We do not have to MGM' If there Is either 'bodily Injury' or 'property lurnlsh these bonds. damage* to which this insurance applies that Is caused by the same *accident,* (3) The cost of blonds to release We have the right and duty to defend any 'Insured' attachments in any 'suit, against the 'insured' we defend, but only for bond against a "suit' asking for such damages or a amourds within our Limit of Insurance. PA9s2 of 11 f" ,r tly �1iz4whq Copyright, ISO PrOPOUS, Inc., 2005 CA 00, 0103 06 06�4 Blank Page ; ; t Bossiness Auto policy MGT of America, 'Inc. Policy 2093563501 SECTION IV BUSINESS AUTO CONDITIONS The following conditions apply in addition to the Common Policy Conditions: A. Lose Conditions I. Appraisal For Physical Damage Loss If you and we disagree on the amount of "loss,' either may demand an appraisal of the 'loss.' In this event, each party will select a competent appraiser. The two appraisers will select a competent and impartial umpire. The appraisers will state separately the actual cash value and amount of 'loss.' If they fail to agree, they will submit their differences to the umpire. A decision agreed to by any two will be binding. Each party will: a. Pay Its chosen appraiser; and b. Bear the other expenses of the appraisal and umpire equally, if we submit to an appraisal, we will stii!I retain our right to deny the claim. 2. Duties In The Event Of Accident, Claim, Suit Or Doss We have no duty to provide coverage under this Policy unless there has been fulfil compliance with the following duties: a. In the event of 'accident,' claim, 'suit" or loss,' you must give us or our authorized representative prompt notice of the 'accident' or "lass' include: (1) How, when and where the 'accident' or "loss" occurred; (2) The 'insured's' name and address; and (3) To the extent possible, the names and addresses of any injured persons and witnesses. b. Additionally, you and any other involved 'insured' must: (1) Assumwa no obligation, make no payment or incur no expense without our consent. except at the 'insured's' own cost. (2) Immediately send us copies of any request, demand, order, notice, summons or legal paper received concerning the claim or 'suit." (3) Cnoperata with us in the Investigation or settlement of the claim or defense against the `salt.' (4) Authorize us to obtain medical records or other perlinent information. (a) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably require. c. If there is 'loss' to a covered "auto" or its equipment you must also do the following: CA 006103 06 (1) Promptly notify the police if the covered `auto' or any of its equipment Is stolen. (2) Take all reasonable steps to protect the covered 'auto' from further damage, Also keep a record of your expenses for consideration in the settlement of the claim. (3) Permit us to inspect the covered 'auto" and records proving the 'loss' before Its repair or disposition. (4) Agree to examinations under oath at our request and give us a signed statement of your answers. 3. Legal ACH011 Against Us No one may bring a Iegai action against us under this Coverage Form until: a. There has been full compliance with all the terms of this Coverage Farm, and b. Under Liability Coverage, we agree in writing that the 'insured' has an obligation to pay or until the amount of that obligation has finally been determined by judgment after Trial, No one has the right under this Policy to bring us into an action to determine the 'insureds' liability. 4. Loss Payment— physical Damage Covera"3 At our option we may: e. Pay tor, repair or replace damaged or stolen prol,any', b. Relearn the stolen property, at our expense, We will pay for any damage that results to the 'auto' from the theft; or ce Take all or any path Of the damaged or stolen property at an agreed or appraised value. it we pay for the '10,39,• our payment will include the applicable sales tax for the damaged or stolen property. S. Transfer Of flights Of Recovery Againstt Others To Us It any person or organization to or for whom we make payment under this Coverage Fortis has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident' or 'loss' to impair them, !B. General Cotwditions 1. Bankruptcy Bankruptcy or insolvency of the "insured' or the 'Insured's' estate will not relieve us of any obligations under this Coverage Form. 2. Concealment, flilsrepresenhdion Or Fraud This Coverage Form is Vold in any case of fraud by you at any time as It relates to ibis Coverage Copyright, ISO Properties, Inc., 2005 p�� fill , `t " i S X° Blank Page -P,— 10 POLICY NIUMBER: 5095130327 COMMERCIAL GENERAL WABIUW CG 24 04 CIS 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modif lea Insurance provided under the following: COMMERCIAL GENERAL LIA131LITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Orglanizst onr Refer to SCHEDULE C'G2404 thls The following Is added to 'Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Seal'ran IV — CandlWans: We waive any right of recovery we may have against the person or organization shown In the Schedule above because of payments we make for Injury or 8 damage arising out of your ongoing operations or 'your 8 work' done under a contract with that parson or organlzation and Included In the 'products- completed operations hazard.' This watver applies only to the parson or organization shown In the Schedule above. a ass 1 CG 24 04 05 09 Copyright, Insurance Services Oft'ice, Inc,, 2008 POO y of I pta,tL "-; - FI lr?4l vk r"� / Blank Page 114e�e POLICY N=B9R INSfURED NAME AND ADDRESS 5095130327 MGT OF AMERICA, INC. TALLAHASSEE, FL POLICY CHANCES CG2504 0509 WAIVER-TRANS RIGHTS RECOVERY AGAINST OTHERS TO U This Change Endorsement changes the Policy. Please read it carefully. Thin Change Endorsement is a part of your Policy and taken affect on the effective date of your Policy, unless another effective date is shown. CG 24 04 SCHEDULE Name of Person or Organization: Any person or organization with whom you have agreed in writing in a contract or agreement to waive any right of recovery against such person or organization, but only if the contract or agreement: 1. Is in effect or becomes effective during the term of this policy; and 2. Was executed prior to loss. Chaknan of ft Bo" 0-56015-B (ED. 11/917 U Socratary Blank Page V /z.f, Guzman, Elizabeth From: Sam Long [siomg@mgtamercom] Sent: Friday, October 10, 2O144:51 AM To: Guzman, Elizabeth Subject: FVV: Certificate Cf Insurance for MGT of America, Inc. Attachments: Cert808488960.pdf; W1GTDF-1 AUTO AU and VVaivorl2-13.pdf; GL' BUenkotAdd1 Unad.pdf; BL-VVO8.pdf; CA-WC BUanketVV(}S.pdf; VVC-VV()S-4U {)ther.pdf Hi Ms. Guzman Please see attached Certificate of Insurance from MGT of America, Inc. for FY 14-15. Please advise if this is not sufficient. Thank You Samuel B. Long Contracts Administrator MGT of America/ Inc. 3800 Esplanade Way, Suite 210 Tallahassee, FL 32311 858-386-3191/ em±, 4342 Fax # 850-385-4501 1