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HomeMy WebLinkAboutDAVIS, LAVERNE 3 -2015City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with N-2015-048 No. was completed on (List all amendments. Use space below if needed.) COTC Office Use Only FFoUCIR OF cNL k�o/aan and final payment has been made. Department: PR C SA Phone/Ext.: `-(U [ CA Signature: Date: Revised 10-31-12 INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES _417u !s CLERK OF COUNCIL{)�rJ DATE; �R 2 U.Pa�ls(.`� RECREATION SERVICES AGREEMENT N-2015-048 ea THIS AGREEMENT is made and entered into this 7th day of April 2015, by and IUebetween LaVerne Davis (hereinafter "Provider") and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California (hereinafter "City"). RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to conduct various fitness classes in its leisure class program. B. Provider represents that Provider is able and willing to provide such set vices to the City. C. In undertaking the performance of this Agreement, Provider represents that he is knowledgeable in its field and that any services performed by Provider order this Agreement will be performed in compliance with such standards as may reasonably be expected. 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 Provider shall perform those services as set forth, in Exhibit A to this Agreement. 2. COMPENSATION' In consideration for the right to provide the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed $25,000 aminally. Payment to Provider shall be made within thirty (30) days following completion of the last class taught by Provider that month. City shall be responsible for collecting all fees from program participants. Provider shall not collect fees but will refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent (30°fi) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall be for two (2) ;}rears, commencing on July 1, 2015 and ending on June 30, 2017, unless tenrrinated earlier in accordance with Section 12 below. 4. INDEPENDENT CONTRACTOR Provider 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 manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider 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. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSUitANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Provider shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Provider's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured's provisions. b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Provider, if Provider 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, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c, The following requirements apply to the insurance to be provided by Provider pursuant to this section: (i) Provider shall maintain all insurance required above in fall force and effect for the entire period covered by this Agreement. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. d. If Provider fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such tenmination shall not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 2 6. INDEMNIFICATION Provider agrees to and shall defend, indemnify and hold harmless the City, its officers, agents, employees, contractors, 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 death, and claims for property damage, which may arise from the direct or indirect operations of the Provider 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 Provider 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 asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arising 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. 7. CONFLICT OF INTEREST Provider 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. 8. LIVE SCAN BACKGROUND CHECK Providers, and any employees, subcontractors or substitutes, in contact with minors under eighteen (18) years of age shall arrange for and submit to a Live Scan electronic background check for criminal history available through the California, Department of Justice as a condition of this Agreement and provide proof of compliance prior to performing services hereunder. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 26 Civic Center Plaza (M-75) P.O. Box 1988 Salta Ana, California 92702 Fax (714) 571-4211 To Provider: LaVeme Davis 2221 S. Lowell Street Santa Ana, CA 92707 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 fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, 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 Provider. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Provider or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 11. ASSIGNMENT/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider 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, b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at, least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 4 12. TERMINATION a, This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section 1 Lb, must be given to the City at least thirty (30) days prior to termination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 13. RECORDS Provider shall use attendance sheets generated and, supplied by the City to record attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. DISCRI.MINATION Provider 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, teaching, training, utilization, promotion, termination or other employment related activities. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California, Both parties further agree that Orange Comity, 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. 16. LICENSES Provider 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 govermnental agencies. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or nmenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. Exhibit A SCOPE OF SERVICES— LaVeme Davis A. Provider will teach various Zwnba Dance class for ages 3 and up. B. Provider shall teach Zumba classes (1) at the times below at a facility to be designated by the City or (2) on a schedule otherwise agreed upon by the parties for each class session or term, including the location, specific days and hours when classes will be held and holidays to be observed, in accordance with the City's needs. • Zumba adults class: Monday through Friday, 1 hour per day, 5 days per week • Zumba kids class: Wednesday and Friday, 50 minutes per day, 2 days per week C. Provider will provide and be responsible for equipment, records, and personnel and clean-up of the facilities and materials necessary to ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 10 paid students and no more than a maximum of 30 or as established by mutual agreement of the City and Provider. B. No registration will be accepted after the second meeting of class. C, In the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Provider will be under no obligation to provide services for the cancelled class, and the City will have no further obligations to pay Provider compensation for the remaining classes that were cancelled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B. Provider may not waive class participation/registration fees. C. Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. 18. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The person{s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to excente this Agreement on behalf of said parties and that be so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: &:�0, 1�11,t1 Maria D. Huizar i1 ' Cleric of the Council GG// APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney John Funk Assistant City Attorney RECOMMENDED FOR fJ 2 d GERARDO MOUI Executive Director Recreation and Coy Services Agency David Cavazos City Manager PROVIDER: LaVerne Davis A C RDTN CERTIFICATE OF LIABILITY INSURANCE OAT/01YYYY) 051265/26I2014 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 corifleale holder is an ADDITIONAL INSURED, the poiloy(les) must be endorsed. if SUBROGATION IS WAIVED, subject tD the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER _ CONTACT NAME: Mass Merchandisin Underwritin 9 9 K&K Insurance Group, Inc. -� _ 1712 Magnavox Way Fort Wayne IN 46804 PHONE: AIC No. Ear: _ 1-800-506-4866 _ _ FAXi(A/C, No): 1-260-459-5590 gODRESS: Info(o)fltne6SinSUrance-kk.cam INSURER(S) AFFORDING COVERAGE NAIC0 INSURER A: Nationwide Mutual Insurance Company 23787 INSURED 8: _ _INSURER Laverne Davis _ INSURER C:.�-�- 2221 s. Lowell St. INSURER D: Santa Ana, CA 92707 A Member of the Sports, Leisure & Entertainment RPG INSURER E; INSURER F� COVERAGES CERTIFICATE NUMBER: W00466618 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 ALI. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OFINSURANCE ADDL INSD SUER WVD POLICY NUMBER P LICYEFr^ MMIDD POLICYEXP MMlDO/YY LIMITS A X COMMERCIAL GENERAL LIABILITY X 68RPO0000005527000 06/08/2014 06/08/2016 EACH OCCURRENCE $1,000100 DLAIMB•MADE X OCCUR 12:01 AM EDT12:01 AM DAMAGE RENrEO PREMISES ocCiurance $300,000 -(Ea MED EXP(Any one person) $5,000 PERSONAL &ADV INJURY $1,000,00 OEN'; AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE �"""_'i POLICY' PRO- ❑ LOC L_I JECT OTHERpnpq a� '.Q ,yv1 5 000 00 PRODUCTS-COMPIDP AGG $1 6D6,g0 PROFESSIONAL LIABILITY $1.000.00 +f'@ V �+ O LEGA _LAB TOPARTICIPANTS $1,000,0O AUTOMOBILE LIABILITY OMe1NED SINGLE LIMIT Ea Accldonl _ BODILY INJURY (Per person) ANY AUTO ALL OWNED AUTOS SCHEDULED urns NON OWNED HIRED AUTOS ON-O L o LISP As F ity At t C)ty Att rney�. �'' 5 BODILY INJURY (Per anddenU PROPERTY DAMAGEL_JAUTOG Not provided while In Hawaii ✓ UMBRELLALIAB OCcuR EACHOCCURRENCE EXCESS LIAS CIAIMS-MADE AGGREGATE �.. DED RETENTION ... WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORSHIP/PARTNER/ EXECUTIVE OFFICERIMEMBER I I EXCLUDED? N/A ""_ "'- _-- _-- — """" PER STATUTE --- OTHER E.L. EACI'I ACCIDENT E.L. DISEASE — EA EMPLOYEE (Mandatory In NH) If yes, dascdbe undor DESCRIPTION OF OPERATIONS below E.L. DISEASE — POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL ERAAdditional amar s c e oo,may rsattac er I moreepcels require CertlBed nstructorof:ZUMBA(R) Tho csrtlilcgte holder Is added as an additional insured but only for liabili caused, it whole or in part, bZ the acts or omissions of the named Insured. [N-'9:4Yf7L+L'VYEI11.L4]iN: The City of Santa Ana and its of cers,employees,agents&representatives SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Cormen Acosta, 1825 W. Civic Center Santa Ana, CA 92701 (OwnerlLessor of Premises) THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE N Coverage Is only extended to U.S. events and activities. '* NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved, POLICY NUMBER: 6BRPG0000005527000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 2.b. is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: LaVerne Davis Additional Insured: The City of Santa Ana and it's officers, employees, agents and representatives Attn: Carmen Acosta 1825 W. Civic Center Santa Ana, CA 92701 Ref: CP# 1203 Effective: 06/08/14 to 06/08/15 9RPG9016 'rO YOW L P E ST NttomeY psslstant City 09/06 POLICY NUMBER: 6BRPG0000005527000 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies Insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured. Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply, Additional Insured: The City of Santa Ana and it's officers, employees, agents and representatives Attn: Carmen Acosta 1825 W. Civic Center Santa Ana, CA 92701 Ref: LaVerne Davis Ref: CP# 1203 Effective; 06/08/14 to 06/08/15 SRPG8018 00 S.f ORCK „/"' �\SA �°C•�tY Attorney Ps515tan �� 09108 POLICY NUMBER: 6BRPG0000005627000 COMMERCIAL GENERAL LIABILITY CO 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, rrA r 11 s 061mel * « . This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises (Part Leased to You): Premises as described in the agreement or lease Ref: LaVern Davis 2. Name of Person(s) or Organization(s) (Additional Insured): The City of Santa Ana and it's officers, employees, agents and representatives Ref: CP# 1203 Attn: Carmen Acosta 1825 W. Civic Center Effective: 06/08/14 to Santa Ana, CA 92701 06/08/15 3. Additional Premium: None Information required to complete this Schedule, if not shown above, will be shown in the Declarations A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to 1. Any "occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. However: The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount ofinsurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations, 00 2011 0413 0Insurance Services Office, Inc., 2012 APPROVED AS TO FORM STTOR Assistant City Attorney L�I Page 1 of 1 POLICY NUMBER: 6BRP00000005627000 INTERLINE IL 12 01 1185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 1aQRWAMLJWe1;N Policy Change Number 1 POLICY NUMBER —[�0610811Y4 POLICY POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000005527000 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE LaVerne Davis K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES Forms CG2011, SRPG8016, SRPG8018 are added to the policy, Ref: CP# 1203 Effective: 06/08/14 to 06/08/15 The above amendments result in a change of premium as follows: 1ENo Change r-1 To be Adjusted at Audit Additional Premium El Return Premium Authorized Representative Sigiiat-tTria- UP-ROV D S TO 'FOY"d 1, LI ORCK A E, Attorney IL 12 01 11 85 Copyright, Insurance Services Office, Inc.. 1983 Page I of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2015-31 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O, Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: La Verne Davis TYPE: Dance 2221 Lowell Street DATE(S): 06/08/15—12/31/15 Santa Ana, CA 92707 LOCATION: El Salvador Center, Santa Anita. VK Plaza Santa Ana *Liquor Liability Yes❑ No® **Liquor Liability after 12 am ends before 2 am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein Is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41017 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2015 EXPIRATION: JANUARY 1, 2016 COMMERCIAL GENERAL LIABILITY OCCURRENCE PORN[ DEDUCTIBLE: NONE General Aggregate Limit $ 2,00000 Products & Completed Openttions 1.000,000 SPECIAL CONDITIONS: Personal & Advertising htjury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) IM000 Certificate Of Insurance' Medical Payments (Awry One Person) .5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased El $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as ifa separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS CANCELLATION Should the above described policy be cancelled before the expiration date thereof, nonce will be delivered in accordance with the policy provisions. AUTHORCZED REPRESENTATIVE: DATE ISSUED: June 8, 2015 by Briza Morales EVANSTON FNSURANCE COMPANY CERTIFICATE NO.: 2016-1.9 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. 0. Box 6450 Santa Ana, CA 92.701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Laverne Davis 'TYPE: Dance 2221 Lowell Street ,�� ( DATE(S): 01/07/16— 12/31/16 Santa Ana, CA 92707 �� LOCATION: El Salvador Center & Santa Anita Center *Liquor Liability Yes ❑ No N "Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special. Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41.020 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUA.RY 1, 2017. COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DE I3UCTIRLE NONE General Aggregate Limit S 2,000,000 Products & Completed Operations 1,000,000 SPECIAL. CONDITIONS: Personal & Advertising hllury 1,000,000 The following endorsements attached to Each Occurrence [,unit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Of Insurance: Medical Payments (Any One Person) 5,000 Liquor Liability (if purchased) 1,000,000 Optional Limits Purchased - , st'000,0001S3,000,000 P [] $2,000,0001$2,000,000 Darnage `Ta Property (If purchased) ICI The limits of insurance apply separately to each event insured by this policy as ife separate po 4' insurance has 'been issued for that event. OTHER ADDITIONAL INSUREDS CA.NCFlJ.,ATION: Should the above described Policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy revisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: January 7 2016 by Briza Morales EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2017-29 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. 0. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: LaVerne Davis TYPE: Dance 2221 Lowell Street DATE(S): 01/30/17 — 12/31/17 Santa Ana, CA 92707 LOCATION: El Salvador Center & Santa Anita Center - *Liquor Liability Yes [I No w(-I'M - ". — 04 "Liquor Liability after 12 am ends before 2 am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions Of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBEW SEP41023 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2017 EXPIRATION: JANUARY 1, 2018 COMMERCIAL GENERAI., LIABILITY OCCURRENCE FORM DEDUCTIBLE,- NONE General Aggregate Limit S2,000,000 Products & Completed Operations 1,000,000 SPIX ' 'IAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Of Insurance: Medical Payments (Any One Person) 5,000 Liquor Liability (if purchased) 1,000,000 Optional Limits Purchased F-1 $1,000,000/$3,000,000 El $2,000,000/$2,000,000 Damage To Property (if purchased) The limits of insurance apply separately to each event insured by this policy as ifa separate policy of insurance has been issued for that eveqt, OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be eed i with the policy 2revisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: January 30, 2017 By Stella Fajardo WORKERS' COMPENSATION DECLARATION LaVerne Davis hereby of under penalty of perjury, the (Name/Title) following declaration I certify on behalf of — LaVerne Davis that during the term of my (Consultant/Company Name) contract for Recreation Class services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage, DATE: A - By: Name: Title: Recreation Class Instructor WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. N55 C 0`0