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HomeMy WebLinkAboutBOYS & GIRLS CLUB OF SANTA ANA (2)-2017City of Santa ` na Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreeffi;W. dncl all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requireQnTs have been satisfied prior to signing the termination form. C L F F ' ',- Is the agreement(s) a permanent record? Yes _ No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with Office Use No. A DLO i 1 —0 Gj 3 was completed on Z-1 O and final payment has been made. (List all amendments. Use space below if needed.) /� Department: � Cl A Phone/Ext.: Signature: Date:Revised: 10-18-16 INSURANCE ON FILE WORK MAY PROCEED UNTIL INSLIRA CE F.XP S 2-ItI CLERK OF COUNCIL. DATE %P In 1 2017 Equipment Coverage insurance Required if Contractor Purchases Equipment AUXLENlE24I I%I WEEN I 14 I,'I'I'Y ONSALV'I'A ANA AND BOYS & GIRLS CLUBS OF CENTRAL ORANGE COAST FOR USE A OF COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS A-2017-093 C,J, p ty QA tv� This Agreement is hereby made and entered into this 1st day of July, 2017, by and between the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("CITY'), and Boys & Girls Clubs of Central Orange Coast, a California nonprofit corporation ("SUBRECIPIENT"). RECITALS: A. The CITY, as an entitlement recipient and grantee of the United States Department of Housing and Urban Development ("HUD") Community Development Block Grant ("CDBG") Entitlement Program, Catalog of Federal Domestic Assistance (CFDA) Number 14.218, and Federal Award Identification Number (FAIN) B -17 -MC -06-0508 , desires to enter this Agreement with the SUBRECIPIENT for the expenditure of CDBG funds in accordance with Title 24, Part 570 of Code of Federal Regulations 24 CFR 570.000, et seg. ("CDBG REGS"). B. CITY has applied for and received CDBG funds from HUD pursuant to Title I of the Housing and Community Development Act of 1974, Public Law 93-383, as amended ("ACT"). C. The SUBRECIPIENT is a private nonprofit corporation that has been selected by the CITY to receive CDBG funds and administer such financial assistance; and to provide the services described in Exhibit A, in accordance with the schedule of performance included therein, hereinafter referred to as "said program". SUBRECIPIENT represents that it is qualified and willing to operate said program and certifies that the activities carried out with funds provided under this Agreement will meet one or more of the CDBG program's National Objectives (24 CFR Part 570.208). D. SUBRECIPIENT agrees that it will adhere to the performance measurements and outcomes as indicated on Exhibit A (Schedule of Performance). Failure to follow the measurements and meet the stated outcomes may constitute breach of contract that could result in termination of this Agreement or serve as reason for the City to recapture the grant funds awarded to SUBRECIPIENT pursuant to this Agreement. WHEREFORE, it is agreed by and between the parties that the foregoing Recitals are a substantive part of this Agreement and the following terms and conditions are approved and together with all exhibits and attachments hereto, shall constitute the entire Agreement between the CITY and SUBRECIPIENT: I. SUBRECIPIENT'S OBLIGATIONS A. Nonprofit Status - Representations and Warranties. (a) Authority. SUBRECIPIENT is a duly organized and existing nonprofit corporation in good standing and authorized to do business under the laws of the State of California. SUBRECIPIENT has full right, power and lawful authority to accept the funding hereunder and to undertake all obligations as provided herein and the execution, performance and delivery of this Agreement by SUB'1ZECIPIENT has been fully authorized by all requisite actions on the part of SUBRECIPIENT. (b) Experience. SUBRECIPIENT is a qualified provider of the services to be provided hereunder. (c) Familiarity With Services Required. By executing this Agreement, SUBRECIPIENT warrants that (i) it has thoroughly investigated and considered the services to be performed and provided hereunder, (ii) it has carefully considered how the services should be performed, and (iii) it fully understands the facilities, difficulties and restrictions attending performance of the services under this Agreement. (d) No Conflict. To the best of SUBRECIPIENT'S knowledge, SUBRECIPIENT'S execution, delivery and performance of its obligations under this Agreement will not constitute a default or a breach under any contract, agreement or order to which SUBRECIPIENT is a party or by which it is bound. (e) No Bankruptcy. SUBRECIPIENT is not the subject of any current or threatened bankruptcy proceeding. (f) No Pending Legal Proceedings. SUBRECIPIENT is not the subject of a current or threatened litigation that would or may materially affect SUBRECIPIENT'S performance under this Agreement. (g) Application Veracity. All provisions of and information provided in SUBRECIPIENT'S application for funding submitted to CITY including any exhibits are true and correct in all material respects. (h) No Pending Investigation. SUBRECIPIENT is not aware that it is the subject of any current or threatened criminal or civil action investigation by any public agency, including without limitation a police agency or prosecuting authority, that would relate to affect performance of the Agreement or provision of services hereunder. B. Amount of Grant/Tenn and Quarterly Disbursement. The amount granted to SUBRECIPIENT is $61,832 ("CDBG FUNDS"), for the term of July 1, 2017 through June 30, 2018. Such funds shall be expended by SUBRECIPIENT on or before June 30, 2018. The Term of this Agreement may be extended by a writing executed by the City Manager, or his or her designee, and the City Attorney. The CDBG FUNDS shall be disbursed by CITY to SUBRECIPIENT on a quarterly basis subject to and upon receipt and approval of a complete quarterly activity report from SUBRECIPIENT, with the final payment subject to the satisfaction of the condition precedent of submittal of complete reporting information due on or before July 15 of the applicable funding year, as hereinafter more fully set forth. SUBRECIPIENT shall be obligated to perform such duties as would normally extend beyond the term, including, but not limited to, obligations with respect to indemnification, audits, reporting, data retention/reporting, and accounting. Failure to provide any of the required documentation and reporting will cause CITY to withhold all or a portion of a request for reimbursement, or return the entire reimbursement package to SUBRECIPIENT, until such documentation and reporting has been received and approved by CITY. The CITY reserves the right to reduce the grant application if the CITY's fiscal monitoring indicates that SUBRECIPIENT's rate of expenditure will result in unspent funds at the end of the program year. Amendments in the grant allocation will be made after consultation with SUBRECIPIENT. C. Use of Funds. SUBRECIPIENT agrees to use all federal funds provided by CITY to SUBRECIPIENT pursuant to this Agreement to operate said program, as set forth in "Exhibit A," attached hereto and by this reference incorporated herein. SUBRECIPIENT'S failure to perform as required may, in addition to other remedies set forth in this Agreement, result in readjustment of the amount of funds CITY is otherwise obligated to pay to SUBRECIPIENT hereunder. D. Allowable Costs. SUBRECIPIENT agrees to complete said program on or before June 30, 2018, and to use said fiords to pay for necessary and reasonable costs allowable Linder the federal law and regulations to operate said program. Said amounts shall include, but not be limited to, wages, administrative costs, and employee benefits comparable to other similarly situated employees, and indirect costs. Other allowable program costs are detailed in the budget, as set forth in "Exhibit B," attached hereto and by this reference incorporated herein. SUBRECIPIENT shall use all income received from said funds only for the same purposes for which said funds may be expended pursuant to the terns and conditions of this Agreement. SUBRECIPIENT has the ability to adjust line item amounts in the budget with the written approval of the CITY's Executive Director of the Community Development Agency, or designee, so long as the total budget amount does not increase. Pursuant to 2 CFR §200.331(a)(4), the Indirect Cost Rate for the SU'BRECIPIENT's award shall be an approved federally recognized indirect cost rate negotiated between the SUBRECIPIENT and the Federal government, or, if no such rate exists, the de minimis indirect cost rate as defined in 2 CFR §200.414(b) Indirect (F&A) costs. For this agreement, the de minimis indirect cost rate of 0% will apply. E. Licensing. SUBRECIPIENT agrees to obtain and maintain all required licenses, registrations, accreditation and inspections from all agencies governing its operations. SUBRECIPIENT shall ensure that its staff shall also obtain and maintain all required licenses, registrations, accreditation and inspections from all agencies governing SUBRECIPIENT's operations hereunder. Such licensing requirements include obtaining a City business license, as applicable. F. Zoning. SUBRECIPIENT agrees that any facility/property used in furtherance of said program shall be specifically zoned and permitted for such use(s) and activity(ies). Should SUBRECIPIENT fail to have the required land entitlement and/or permits, thus violating any local, state or federal rules and regulations relating thereto, SUBRECIPIENT shall immediately make good -faith efforts to gain compliance with local, state or federal rules and regulations following written notification of said violation(s) from the CITY or other authorized citing agency. SUBRECIPIENT shall notify CITY immediately of any pending violations. Failure to notify CITY of pending violations, or to remedy such lmown violation(s) shall result in termination of grant funding hereunder. SUBRECIPIENT must make all corrections required to bring the facility/property into compliance with the law within sixty (60) days of notification of the violation(s); failure to gain compliance within such time shall result in termination of grant funding hereunder. G. Separation of Accounts. All funds received by SUBRECIPIENT from CITY pursuant to this Agreement shall be maintained in an account in a federally insured banking or savings and Loan institution with record keeping of such accounts maintained pursuant to applicable 2 CFR 200.302 requirements. SUBRECIPIENT is not required to maintain separate depository accounts for CDBG FUNDS; provided however, the SUBRECIPIENT must be able to account for receipt, obligation and expenditure of CDBG FUNDS pursuant to applicable 2 CFR 200.302 requirements. H. Audit Report 'Requirements. SUBRECIPIENT agrees that if SUBRECIPIENT expends Seven Hundred Fifty Thousand Dollars ($750,000) or more in federal funds, SUBRECIPIENT shall have an annual audit conducted by a certified public accountant in accordance with the standards as set forth and published by the United States Office of Management and Budget. SUBRECIPIENT shall provide CITY with a copy of said audit by April 1 of the year following the program year in which this Agreement is executed. I. Record Keeping/Reporting. SUBRECIPIENT shall keep and maintain complete and adequate records and reports on program participants to determine their initial and continuing eligibility for the program services being provided to assist CITY in meeting and maintaining its record keeping responsibilities tinder the CDBG REGS, including the following: (1) Records a. Documentation evidencing program income requirements in conformity with 24 CFR 570.504(b((2)(i), (ii) and 24 CFR 570.503(b)(3) and 24 CFR 570.208(a)(2)(B) of the income level of persons and/or families participating in or benefiting by the SUBRECIPIENT program. b. Documentation of the number of persons and/or families participating in or benefiting by the SUBRECIPIENT program. c. Household information shall include number of persons, identification of head of household, race/ethnicity, and income verification of all household members ages 18 and over. d. Documentation of all CDBG FUNDS received from CITY. e. Documentation of expenses as identified in the Budget Proposal, including evidence of incurring the expense, invoices for goods or services, copies of any and all contracts or documentation pertaining to costs for subcontractors, plus all other invoices and proof of payment for which CDBG FUNDS were expended, and any payments therefor. f Any such other related records as CITY shall reasonably require or as required to be maintained pursuant to the CDBG REGS. (2) Reports a. Payment Request. Concurrently with the submittal of each quarterly report, on or before the 15th day of October, January, April and July, SUBRECIPIENT shall submit both: an original invoice/request for reimbursement and true copies of invoices, receipts, canceled checks, bank statements, credit card statements, procurement documentation for goods or services, timesheets, payroll records, benefit statements, agreements, contracts or documentation pertaining to costs for subcontractors, and/or other documentation supporting and evidencing how the CDBG FUNDS have been expended during the applicable quarter. b. Quarterly Progress Report. SUBRECIPIENT agrees to keep records of all ethnic and racial statistics of persons and families benefited by SUBRECIPIENT in the performance of its obligations under this Agreement, including, but not limited to, the number of low and moderate income persons and households assisted in accordance with federal income limits, the number of female heads of households assisted, new program information and year-to-date program statistics on expenditures, caseload and activities. Failure to provide any of the required documentation and reporting will cause CITY to withhold all or a portion of a request for reimbursement, or return the entire reimbursement package to SUBRECIPIENT, until such documentation and reporting has been received and approved by CITY. J. Access to Records. CITY and the United States Government and their representatives or auditors shall have access for purposes of monitoring, auditing, and examining SUBRECIPIENT's activities and performance, to books, documents and papers, and the right to examine records of SUBRECIPIENT's subcontractors, bookkeepers and accountants, employees and participants in regard to 4 said program. CITY and the United States Government and their representatives or auditors shall also schedule on-site monitoring at their discretion. Monitoring activities may also include, but are not limited to, questioning employees and participants in said program and entering any premises or any site in which any of the services or activities funded hereunder is conducted or in which any of the records of SUBRECIPIENT are kept. Nothing herein shall be construed to require access to any privileged or confidential information as set forth in federal or state law. K. Location of Records/Required Leneth of Record Kee in . All accounting records, reports, and evidence pertaining to all costs, expenses and the CDBG FUNDS of SUBRECIPIENT and all documents related to this Agreement shall be maintained and kept available at SUBRECIPIENT'S office or place of business for the duration of the Agreement and thereafter for five (5) years from the date of final payment under this Agreement. Records which relate to (a) complaints, claims, administrative proceedings or litigation arising out of the performance of this Agreement, or (b) costs and expenses of this Agreement to which CITY or any other governmental agency takes exception, shall be retained beyond the five (5) years until complete resolution or disposition of such appeals, litigation claims, or exceptions. In the event SUBRECIPIENT does not make the above -referenced documents available within the city of Santa Ana, California, SUBRECIPIENT agrees to pay all necessary and reasonable expenses incurred by CITY in conducting any audit at the location where said records and books of account are maintained. L. Compliance with Law/Program Income. SUBRECIPIENT acknowledges that the funds being provided by CITY for said program are received by CITY pursuant to the ACT as amended and that expenditures of these funds shall be in accordance with the ACT and all pertinent regulations issued by agencies of the federal government, including, but not limited to, all regulations found at Title 24 of the Code of Federal Regulations. Program income received by SUBRECIPIENT shall be returned to CITY unless otherwise provided for in this Agreement. SUBRECIPIENT agrees to comply fully with all federal, state and local laws and court orders applicable to its operation whether or not referred to in this Agreement. M. Debarment. To protect the public interest and ensure the integrity of Federal programs, CITY may only conduct business with responsible persons and may not make any award or permit any award to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549, "Debarment and Suspension". See also 24 CPR 570.609. SUBRECIPIENT must review and sign Exhibit C "Debarment", which is attached hereto and incorporated herein by this reference. SUBRECIPIENT shall be in good standing, without suspension by the California Secretary of State, Franchise Tax Board and Internal 'Revenue Service. Any change in the corporate status or suspension of SUBRECIPIENT shall be reported immediately to CITY. N. Confidentiality. Without prejudice to any other provisions of this Agreement, SUBRECIPIENT shall, where applicable, maintain the confidential nature of information provided to it concerning participants in accordance with the requirements of federal and state law. However, SUBRECIPIENT shall submit to CffY and or HUD or its representatives, all records requested, including audit, examinations, monitoring and verifications of reports submitted by SUBRECIPIENT, costs incurred and services rendered hereunder. O. Independent Contractor. SUBRECIPIENT agrees that the performance of obligations hereunder is rendered in its capacity as an independent contractor and that it is in no way an agency of CITY. P. Violation of Terms and Conditions. SUBRECIPIENT agrees that if SUBRECIPIENT violates any of the terms and conditions of this Agreement or any prior Agreement whereby CDBG funds were received by SUBRECIPIENT, or if SUBRECIPIENT reports inaccurately, or if on audit there is a 5 disallowance of certain expenditures, SUBRECIPIENT agrees to remedy the acts or omissions causing the disallowance and repay CITY all amounts spent in violation thereof. If SUBRECIPIENT engaged in fraudulent activity to obtain and/or justify expenditure of the CDBG funds granted hereunder, SUBRECIPIENT shall be required to reimburse the CITY of all such funds that were obtained and/or spent under fraudulent circumstances. Q. Equipment. SUBRECIPIENT agrees to maintain a record for each item of non-expendable personal property acquired under the terms of this Agreement. Said record shall be made available to CITY upon request. The term "non-expendable personal property" shall include leased and purchased equipment. R. Prohibited Use. SUBRECIPIENT hereby certifies and agrees that it will not use fonds provided through this Agreement to pay for entertainment, meals or gifts, or other prohibited uses. S. Lobbvine. SUBRECIPIENT certifies that it will comply with federal law (31 U.S.C. 1352) and regulations found at 24 CPR Part 87, which provide that no appropriated funds may be expended by the recipient of a federal contract, grant, loan or cooperative agreement to pay any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, or an officer or employee of a Member of Congress in connection with awarding of any federal contract, the making of any federal grant or loan, entering into any cooperative agreement and the extension, renewal, amendment or modification of any federal contract, grant, loan or cooperative agreement. SUBRECIPIENT shall sign a certification to that effect in a form as set forth in "Exhibit 'D," attached hereto and by this reference incorporated herein. SUBRECIPIENT shall submit said signed certification to CITY prior to performing any of its obligations under this Agreement and prior to any obligation arising on the part of CITY to pay any sums to SUBRECIPIENT under the terms and conditions of this Agreement. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a. Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit a "Disclosure Form to Report Lobbying," in accordance with its instructions (Exhibit D). SUBRECIPIENT shalt require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontractors, sub-grants, and contracts under grants, loans, and cooperative agreements), and agrees to take all actions necessary to ensure that all subrecipients shall similarly certify and disclose accordingly. T. Financial Interest. SUBRECIPIENT agrees that except for the use of CDBG funds to pay salaries and other related administrative or personnel costs, no persons who exercise or have exercised any function with respect to CDBG activities assisted under the terms of this Agreement, or who are in a position to participate in a decision-making process or gain inside information with regard to such activities, may obtain a financial interest or benefit from a CDBG-assisted activity of SUBRECIPIENT, either for themselves or those with whom they have family or business ties, during their tenure or for one year thereafter. This prohibition applies to any person who is an employee, agent, consultant, officer, or elected or appointed official of CITY, or of any designated public agency, or the SUBRECIPIENT. U. Labor Standards. The SUBRECIPIENT agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis-Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act (40 U.S.C. 327 or seq.) and all other applicable Federal, state and local laws and regulations pertaining to labor standards insofar as those acts apply to the performance of this Agreement. The SUBRECIPIENT agrees to comply with the Copeland Anti-Kick Back Act (18 U.S.C. 874 et seq.) and its implementing regulations of the U.S. Department of Labor at 29 CFR Part 5. The SUBRECIPIENT shall maintain documentation that demonstrates compliance with hour and wage requirements of this part. Such documentation shall be made available to the CITY for review upon request. SUBRECIPIENT agrees that, except with respect to the rehabilitation or construction of residential property containing less than eight (8) units, all contractors engaged under contracts in excess of $2,000.00 for construction, renovation or repair work financed in whole or in part with assistance provided under this contract, shall comply with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the regulations of the Department of Labor, under 29 CFR Parts 1, 3, 5 and 7 governing the payment of wages and ratio of apprentices and trainees to journey workers; provided that, if wage rates higher than those required under the regulations are imposed by state or local law, nothing hereunder is intended to relieve the SUBRECIPIENT of its obligation, if any, to require payment of the higher wage. The SUBRECIPIENT shall cause or require to be inserted in fill, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. V. Section 3 of the Housing and Urban 'Development Act of 1968. SUBRECIP ENT will make every effort to provide training opportunities for low -and moderate -income persons residing within the community where the construction project is located and contracts awarded to local businesses therein to the greatest extent feasible as required under the provisions of Section 3 of the Housing and Urban Development Act of 1968, the regulations set forth in 24 CFR 135, and all applicable rules and orders issued hereunder prior to the execution of this Agreement. Compliance with the foregoing requirements shall be a condition of the federal financial assistance provided tinder this Agreement and binding on the SUBRECIPIENT. Failure to fulfill these requirements shall subject the SUBRECIPIENT, its successors and designees, to those sanctions specified by the Agreement though which federal assistance is provided. The SUBRECIPIENT certifies and agrees that no contractual or other disability exists which would prevent compliance with these requirements. SUBRECIPIENT shall make every effort to ensure that all projects funded wholly or in part by CDBG funds shall provide equal employment opportunities for minorities and women. W. Drug Free Workplace. SUBRECIPIENT agrees to provide a drug-free work place and to execute a certification as set forth in "Exhibit E" attached hereto and incorporated herein by this reference, X. Uniform Administrative Requirements Cost Principles and Audit Requirements for Federal Awards. The following requirements and standards must be complied with: 2 CFR Part 200 et al. SUBRECIPIENT shall procure all materials, property, or services in accordance with the requirements of 2 CFR 200.318-326. Y. Subpart K of 24 CFR 570., SUBRECIPIENT will carry out its activities in compliance with the requirements of Subpart K of 24 CFR 570, however SUBRECIPIENT does not assurne the CITY's enviromnerrW responsibilities or the responsibility for initiating the environmental review process under 24 CFR Part 52. Z. Women- and Minority -Owned Businesses (W/MBE) SUBRECIPIENT will use its best efforts to afford small businesses, minority business enterprises, and women's business enterprises the maximum practicable opportunity to participate in the performance of this Agreement in accordance with the requirements of 2 CFR 200.321 "Contracting with small and minority businesses, women's business enterprises, and labor surplus area firms". As used in this Agreement, the term "small business" means a business that meets the criteria set forth in section 3(a) of the Small Business Act, as amended (15 U.S.C. 632), and "minority and women's business enterprise" means a business at least fifty-one percent (51%) owned and controlled by minority group members or women. For the purpose of this definition, "minority group members" are African-Americans, Spanish-speaking, Spanish surnamed or Spanish - 7 heritage Americans, Asian -Americans, arid American Indians. SUBRECIPIENT may rely on written representations by businesses regarding their status as minority and female business enterprises in lieu of an independent investigation. 11. CITY'S OBLIGATIONS A. Payment of Funds. On July 1, 2017, the CITY was allocated $5,284,229 for fiscal year 2017- 2018 from the United States Department of Housing and Urban Development ("HUD") Community Development Block Grant ("CDBG") Entitlement Program. CITY agrees to pay to SUBRECIPIENT when, if and to the extent federal funds are received a sun not to exceed Sixty -One Thousand Eight Hundred Thirty -Two Dollars ($61,832) for SUBRECIPIENT'S performance in accordance with the Budget attached hereto as "Exhibit B" during the period of this Agreement. Payments shall be made to SUBRECIPIENT through the submission of invoices/reimbursement requests. CITY shall pay such invoices/reimbursement requests within thirty (30) days after receipt thereof provided CITY is satisfied that such expenses have been incurred and documented within the scope and provisions of this Agreement and that SUBRECIPIENT is in compliance with the terms and conditions of this Agreement. Failure to provide any of the required documentation and reporting will cause CITY to withhold all or a portion of a request for reimbursement, or return the entire reimbursement package to SUBRECIPIENT, until such documentation and reporting has been received and approved by CITY. Documentation may include, but is not limited to true copies of invoices, receipts, canceled checks, batik statements, credit card statements, procurement documentation for goods or services, timesheets, payroll records, benefit statements, agreements, contracts or documentation pertaining to costs for subcontractors, and/or other documentation supporting and evidencing how the CDBG FUNDS have been expended during the applicable quarter. B. Audit of Account. CITY shall include an audit of the account maintained by SUBRECIPIENT in CITY's annual audit of all CDBG FUNDS in accordance with Title 24 of the Code of Federal Regulations and other applicable federal laws and regulations. C. Common Rule: Pursuant to 2 CFR 200.328(a), the CITY manages the day-to-day operations of each grant and subgrant supported activities. CITY staff has detailed knowledge of the grant program requirements and monitors grant and subgrant supported activities to assure compliance with Federal requirements. Such monitoring covers each program, function and activity and performance goals are reviewed periodically. D. Environmental Review: In accordance with 24 CFR 58, the CITY is responsible for undertaking environmental review and maintaining environmental review records for each applicable project. E. Performance Monitorine: CITY shall monitor the performance of SUBRECIPIENT against goals and performance standards required herein. The SUBRECIPIENT shall be responsible to accomplish the levels of performance as set forth in Exhibit A and report such measures quarterly to the CITY. If the SUBRECIPIENT estimates such goals will not be met, the SUBRECIPIENT is to contact the CITY, at which time the CITY will determine if any adjustments to the grant award is appropriate. Substandard performance as determined by the CITY will constitute non-compliance with this Agreement. Should the CITY determine that the SUB'RECIPIENT has not performed its obligations as stated in this contract in a satisfactory manner, or if the CITY determines that insufficient supporting information has been submitted, the CITY shall notify the SUBRECIPIENT in writing of its determination specifying in full detail the objections which it has to the SUBRECIPIENT's performance. If action to correct such substandard performance is not taken by the SUBRECIPIENT after being notified by the CITY, within a reasonable period of time as stipulated in the written notification, contract suspension or termination procedures will be initiated. A. SUBRECIPIENT agrees to comply with Executive Order 11246 which requires that during the performance of this Agreement, SUBRECIPIENT agrees not to discriminate against any employee or applicant for employment because of race, religion, sex, color or national origin. Such action shall include, but not be limited to the following: employment, upgrading, demotion, or transfer, rates of pay or other forms of compensation, and selection for training, including apprenticeship. SUBRECIPIENT agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the SUBRECIPIENT setting forth the provisions of this nondiscrimination clause. B. SUBRECIPIENT agrees to comply with Title VI of the Civil Rights Act of 1964 which indicates that no person shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program of activity receiving federal financial assistance. C. No person shall, on the grounds of race, sex, creed, color, religion, marital status, national origin, age, sexual orientation, or physical or mental handicap be excluded from participation in, be refused the benefits of, or otherwise be subject to discrimination in any activities, programs or employment supported by this Agreement. SUBRECIPIENT is prohibited from discrimination on the basis of age or with respect to an otherwise qualified handicapped person as provided for under Section 109 of the Housing and Community Development Act of 1974, as amended. D. SUBRECIPIENT agrees to comply with the Age Discrimination Act of 1975 which requires that during the performance of this Agreement, SUBRECIPIENT agrees not to discriminate against any employee or applicant for employment because of age. Such action shall include, but not be limited to the following: employment upgrading, demotion, or transfer, rates of pay or other forms of compensation, and selection for training, including apprenticeship. SUBRECIPIENT agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the SUBRECIPIENT setting forth the provisions of this age discrimination clause. E. SUBRECIPIENT agrees to comply with Section 504 of the Rehabilitation Act of 1973 which requires that no otherwise qualified individual with a disability in the United States, shall, solely by reason of his or her disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance or under any program or activity conducted by any executive agency or by the United States Postal Service. IV. CONFLICT OF INTEREST Pursuant to the conflict of interest requirements set forth in 24 CFR 570.611 and 2 CFR 200.112, SUBRECIPIENT certifies that no member, officer, employee, agent or assignee of CITY having direct or indirect control of any CDBG monies granted to the CITY, inclusive of the subject CDBG FUNDS, shall serve as an officer of SUBRECIPIENT. Further, any conflict or potential conflict of interest of any officer of SUBRECIPIENT shall be fully disclosed in writing prior to the execution of this Agreement and said writing shall be attached and deemed fully incorporated as a part hereof. Notice shall be sent by SUBRECIPIENT to CITY regarding any changes or modifications to its board of directors and list of officers. V. SPECIAL CERTIFICATION FOR RELIGIOUS ENTITIES If SUBRECIPIENT is a religious entity, SUBRECIPIENT hereby agrees that in connection with the provision of the services SUBRECIPIENT shall provide with CDBG funds, in accordance with 24 CFR 570.200x): A. SUBRECIPIENT shall not discriminate against any employee or applicant for employment on the basis of religion and shall not limit employment or give preference in employment to persons on the basis of religion. B. SUBRECIPIENT shall not discriminate against any person applying for the services SUBRECIPIENT agrees to provide under the terms of this Agreement on the basis of religion and shall not limit such services or give preference to applicants for such services on the basis of religion. C. SUBRECIPIENT shall NOT provide religious instruction or counseling, conduct any religious worship or services, or engage in any religious proselytizing, or exert any religious influence in the provision of the services in said program. The parties agree that this covenant is intended to and shall be construed for the limited purpose of assuring compliance with respect to the use of CFFY £ands by SUBRECIPIENT with applicable constitutional limitations respecting the establishment of religion as set forth in the establishment clause under the First Amendment of the United States Constitution and Article I, Section 4 of the California Constitution, and is not in any manner intended to restrict other activities of SUBRECIPIENT. D. The portion of a facility used to provide public services assisted in whole or in part under this Agreement shall contain no sectarian or religious symbols. E. Where the services to be provided ander said program are rendered on property owned by the primarily religious entity SUBRECIPIENT, CDBG funds may also be used for minor repairs to such property which are directly related to the cost of rendering the services Linder said program, where the cost constitutes in dollar terms only an incidental portion of the CDBG expenditure for rendering the services ander said program. VI. PROHIBITION OF NEPOTISM SUBRECIPIENT agrees not to hire or permit the hiring of any person to fill a position funded through this Agreement if a member of that person's immediate family is employed in an administrative capacity by SUBRECIPIENT. For the purposes of this section, the term "immediate family" means spouse, child, mother, father, brother, sister, brother-in-law, sister-in-law, father-in-law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, niece, nephew, stepparent and stepchild. The term "administrative capacity" means having selection, hiring, supervisor or management responsibilities. VII. NOTICES Notices to the parties shall, unless otherwise requested in writing, be sent by U.S. Mail, postage prepaid, and addressed as follows: TO CITY: City of Santa Ana Community Development Agency (M-25) 20 Civic Center Plaza P.O. Box 1988 Santa Ana, California 92702-1988 10 TO SUBRECIPIENT: Robert Santana Boys & Girls Club of Central Orange Coast 250 N. Golden Circle, Suite 104 Santa Ana, CA 92705 None of the duties of, or work to be performed by, SUBRECIPIENT tinder this Agreement shall be subcontracted or assigned to any agency, consultant, or person without the prior written consent of CITY. SUBRECIPIENT must submit all subcontracts and other agreements that relate to this Agreement to CITY. No subcontract or assignment shall terminate or alter the legal obligations of SUBRECIPIENT pursuant to this Agreement. LX. HOLD HARMLESS SUBRECIPIENT shall indemnify, defend and save harmless CITY, its officers, employees, agents, representatives and volunteers from and against any and all damages to or for loss of use of property and for injuries to or death of any person or persons, including property and employees or agents of CITY, and shall defend, indemnify and save harmless CITY, its officers, employees, agents, representatives and voltmteers from and against any and all claims, demands, suits, actions or proceedings of any kind or nature, including, but not by way of limitation, workers compensation claims and including attorney fees and reasonable expenses for litigation or settlement, resulting from or arising out of the negligent or wrongful acts, errors or omissions of SUBRECIPIENT, its officers, directors, employees, agents, subcontractors and suppliers arising out of SUBRECIPIENT's performance of this Agreement. X. INSURANCE 1. Commercial General Liability. SUBRECIPIENT agrees to obtain and keep in force during the term of this Agreement a policy of comprehensive commercial public liability insurance insuring the CITY, and SUBRECIMENT against any liability for accident, injury or death arising out of or in consequence of this Agreement. Such insurance shall be in an amount not less than One Million Dollars ($1,000,000.00) for any injury to or death of any person or persons in any single accident or occurrence. Said policy of comprehensive liability insurance shall be endorsed to provide to CITY at least thirty (30) days written notice prior to cancellation; name CITY, its officers, agents, employees, and volunteers, additional insured; and state that such coverage is primary to any other coverage or self- insurance and CITY. Governmental entities may provide proof of self-insurance. (a) Such insurance shall: (1) name the City of Santa Ana, its officers, agents, representatives, employees and volunteers as additional insured's; (2) be primary with respect to insurance or self-insurance programs maintained by the CITY; (3) contain standard separation of insured's provisions; and (4) give to CITY prompt and timely notice of claim made or suit instituted arising out of SUBRECIPIENT's operations hereunder. (b) SUBRECIPIENT shall: (1) prior to exercising any right under this Agreement, furnish properly executed certificates of insurance and additional insured endorsement to the CITY which shall clearly evidence all coverages required above; (2) provide that such insurance shall not be materially changed or terminated except on 30 days prior written notice to the CITY; (3) maintain such insurance for the period covered by this Agreement; and (4) replace such certificates for policies expiring prior to the expiration of this Agreement It 2. Automobile Liability Coverage. SUBRECIPIENT shall also obtain and maintain, during the effective period of this Agreement, broad form automobile liability coverage with a $1,000,000 limit unless reduced by CITY, which applies to both owned/leased and non -owned automobiles used by SUBRECIPIENT employees or participants in performance of this Agreement, or, in the event that SUBRECIPIENT will not utilize such owned/leased automobiles but intends to require employees, participants or other agents to utilize their own automobiles in the performance of this Agreement, SUBRECIPIENT shall secure and maintain on file from all such employees, participants, or agents as self -certification of automobile insurance coverage. Governmental entities may provide proof of self- insurance. 3. Workers' Compensation. If SUBRECIPIENT is an "employer", as set forth in California Labor Code Section 3300 et seq., or utilizes participants as "employees," as set forth in California Labor Code Section 3350 et seq., SUBRECIPIENT shall obtain and keep in force during the term of this Agreement full Workers' Compensation insurance coverage for injuries suffered by participants. Said insurance policy shall guarantee CITY at least thirty (30) days written notice of cancellation or modification. 4. Equipment Coverage. SUBRECIPIENT shall purchase a policy or policies of insurance covering loss or damage to any and all Equipment provided to or purchased by SUBRECIPIENT in accordance with this Agreement. Said insurance shall be in the amount of the full replacement value thereof„ providing protection against the classification of fire, extended coverage, vandalism, malicious mischief, theft, and special extended perils. Governmental entities may substitute a certificate of self- insurance. 5. Proof of Insurance. Certificates and endorsements must be submitted and approved by CITY prior to any work under this Agreement. SUBRECIPIENT understands that CITY will make no payments under this Agreement until the required certificates and endorsements have been approved by CITY. XI. REVERSION OF ASSETS A. Upon the expiration of this Agreement, SUBRECIPIENT shall transfer to CITY any CDBG funds on hand at the time of the expiration of this Agreement as well as any accounts receivable attributable to the use of CDBG funds. [24 CFR 570.503(b)(7)] B. Any real property under SUBRECIPIENT's control that was acquired or improved in whole or in part with CDBG fiords in excess of $25,000.00 must either be: 1. Used, where CITY has given written approval, to meet one of the national objectives stated in 24 CFR 570.208 until five (5) years after expiration of this Agreement, or for such longer period of time as determined to be appropriate by CITY; or 2. If not used in accordance with subparagraph I above, SUBRECIPIENT shall pay to CITY an amount equal to the current fair market value of the property less any portion of the value attributable to the expenditure of non-CDBG funds for acquisition of, or improvement to, the property. Such payment is program income to CITY. C. Subject to the obligations set forth herein, title to equipment acquired under the terms of this Agreement will vest upon acquisition in SUBRECIPIENT. When said equipment which has been acquired in accordance with this Agreement and all applicable regulations is no longer needed for said program, disposition of said equipment will be made as follows: 12 I . Items of equipment with a current per limit fair market value of less than $5,000.00 may be retained, sold or otherwise disposed of with no further obligation to CITY. 2. Items of equipment with a current fair market per unit value of $5,000.00 or more may be retained or sold and CITY shall have the right to an amount calculated by multiplying the current market value or proceeds from the sale by CITY's share of federal funds used to acquire the equipment, in accordance with 2 CFR 200.313(e)(2). D. SUBRECIPIENT hereby agrees, upon the demand of CITY, to execute, acknowledge and deliver, or cause any person or entity who may have any claim to rights hereunder or under any document, instrument or agreement executed in furtherance of the services and activities to be performed hereunder, to execute, acknowledge and deliver, to CITY assignment(s), quit claim deed(s) or such other and further instruments, documents and agreements as may be necessary, in the sole and absolute discretion of CITY, to vest in CITY all of SUBRECIPIENT's right, title and interest (if any it may have) in and to CITY, CDBG or other federal, state and/or local accounts or program funds or allocation of funds to which CITY is or may be entitled, either for its own account or as fiduciary or trustee for others, which were obtained for the purpose of the performance of this Agreement or any previous agreements relating to the same subject matter or activities as this Agreement, together with any instruments, loans, grants or advances by SUBRECIPIENT on behalf of CITY. in furtherance of the activities hereunder or thereof. SUBRECIPIENT's obligations and responsibilities set forth in this paragraph "XI. REVERSION OF ASSETS," and in paragraph "XII. TERMINATION" and other requirements pertaining to program income shall not be affected by the termination of this Agreement and shall survive the date of termination of this Agreement for such period of time as CITY and/or HUD deems necessary for the responsibilities, duties and obligations to be performed and completed to the satisfaction of CITY and FID. XII. TERMINATION A. This Agreement may be terminated on thirty (30) days' written notice by either party. In the event of such termination, SUBRECIPIENT shall only be entitled to reimbursement for approved expenses incurred to the effective date of termination. B. This Agreement may be suspended or terminated by CITY upon five (5) days' written notice for violation by SUBRECIPIENT of Federal Laws governing the use of Community Development Block Grant Funds. In the event of such suspension or termination, SUBRECIPIENT shall only be entitled to reimbursement for approved expenses incurred up to the effective date of suspension or termination. C. Pursuant to 2 CFR 200.340, in the event SUBRECIPIENT defaults by failing to fulfill all or any of its obligations hereunder, CITY may declare a default and termination of this Agreement by written notice to SUBRECIPIENT, which default and termination shall be effective on a date stated in the notice which is to be not less than ten (10) days after certified mailing or personal service of such notice, unless such default is cured before the effective date of termination stated in such notice. If terminated for cause, CITY shall be relieved of further liability or responsibility under this Agreement, or as a result of the termination thereof, including the payment of money, except for payment for approved expenses incurred for services satisfactorily and timely performed prior to the mailing or service of the notice of termination, and except for reimbursement of (1) any payments made for services not subsequently performed in a timely and satisfactory manner, and (2) costs incurred by CITY in obtaining substitute performance. D. The grant of funds under this Agreement may be terminated for convenience by either the CITY or SUBRECIPIENT, in whole or in part, by setting forth the reasons for such termination, the effective date, 13 and, in the case of portion termination, their portion to b terminated, however, if in the case of a partial termination, the CITY determines that the remaining portion of the award will not accomplish the purpose for with the award was made, the CITY may terminate the award in its entirety. E. The grant of fiords under this Agreement may be terminated due to the non-performance of SUBRECIPIENT and/or failure of SUBRECIPENT to perform the work described in Exhibits A and B or failure to meet the performance standards and program goals set forth therein. F. In the event this Agreement is terminated as set forth in subparagraphs XII.A. through XILE., inclusive, SUBRECIPIENT agrees to immediately return to CITY upon CITY's demand and prior to any adjudication of SUBRECIPIENT's rights, any and all funds not used, and to comply with paragraph "XI. REVERSION OF ASSETS" of this Agreement. XIII. LIMITATION OF FUNDS The United States of America, through HUD, may in the future place programmatic or fiscal limitations on the use of CDBG funds which limitations are not presently anticipated. Accordingly, CITY reserves the right to revise this Agreement in order to take account of actions affecting HUD program funding. In the event of funding reduction, CITY may, in its sole and absolute discretion, reduce the budget of this Agreement as a whole or as to costs category, may limit the rate of SUBRECIPIENT's authority to commit and spend funds, or may restrict SUBRECIPIENT's use of both its uncommitted and its unspent funds. Where HUD has directed or requested CITY to implement a reduction in funding, in whole or as to a cost category, with respect to funding for this Agreement, CITY's City Manager or delegate is authorized to act for CITY in implementing and effecting such a reduction and in revising, modifying, or amending the Agreement for such proposes. If such a reduction in funding occurs, SUBRECIPIENT shall be permitted to de -scope accordingly. Where CITY has reasonable grounds to question SUBRECIPIENT's fiscal accountability, financial soundness, or compliance with this Agreement, CITY may suspend the operation of this Agreement for up to sixty (60) days upon five (5) days written notice to SUBRECIPIENT of its intention to so act, pending an audit or other resolution of such questions. In no event, however, shall any revisions made by CITY affect expenditures and legally binding commitments made by SUBRECIPIENT before it received notice of such revision, provided that such amounts have been committed in good faith and are otherwise allowable and that such commitments are consistent with HUD cash withdrawal guidelines. XIV. EXCLUSIVITY AND AMENDMENT OF AGREEMENT This Agreement supersedes any and all other agreements, either oral or in writing, between the parties hereto with respect to the use of CITY's CDBG funds by SUB'RECIPIENT and contains all the covenants and agreements between the parties with respect to such employment in any manner whatsoever. 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, and that no other agreement or amendment hereto shall be effective unless executed in writing and signed by both CITY and SUBRECIPIENT. XV. LAWS GOVERNING THIS AGREEMENT This Agreement shall be governed by and construed in accordance with the laws of the State of California, and all applicable federal laws and regulations. 14 XVI. CLOSE-OUT The SUBRECIPIENT agrees to comply with the closeout procedures detailed in 2 CFR §200.343, including the following: 1. SUBRECIPIENT must submit, no later than ninety (90) calendar days after the end date of the period of performance, all financial, performance, and other reports as required by the terms and conditions of the Federal award; 2. Unless the CITY authorizes an extension, SUBRECIPIENT must liquidate all obligations incurred under the Federal award not later than ninety (90) calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award; 3. SUBRECIPIENT must promptly refund any balances of unobligated cash that the CITY paid in advance or paid and that is not authorized to be retained by SUBRECIPIENT for use in other projects (See OMB Circular A-129 and 2 CFR §200.345); 4. SUBRECIPIENT must account for any real and personal property acquired with Federal funds or received from the Federal government in accordance with 2 CFR §§200.310- 200.316 and 200.329; and, 5. The CITY should complete all closeout actions for the Federal award no later than one year after receipt and acceptance of all required final reports. XVII. VALIDITY AND SEVERABILITY The invalidity in whole or in part of any provision of this Agreement shall not void or affect the validity of any other provision of this Agreement. Whenever possible, each provision of this AGREEMENT shall be interpreted in such manner as to be effective and valid under applicable law, but if any provision of this AGREEMENT is held to be prohibited by or invalid under applicable law, such provision shall be ineffective only to the extent of such prohibition or invalidity, without invalidating the remainder of such provisions of this AGREEMENT. XVIII. WAIVER No delay or omission by either party hereto to exercise any right or power accruing upon any noncompliance or default by the other party with respect to any of the terms of this Agreement shall impair any such right or power or be construed to be a waiver thereof. A waiver by either of the parties hereto of any of the covenants, conditions, or agreements to be performed by the other shall not be construed to be a waiver of any succeeding breach thereof or of any other covenant, condition or agreement herein contained. XIX. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully, including reasonable costs and attorney's fees, for any injuries or damages to CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. 1.5 b. All Exhibits and Attachments referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. (Signatures on followingpage) 16 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and year written below. ATTEST: )woe J + MARIA D. HUIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO RECOMMENDED FOR APPROVAL: ROBERT C. C RTEZ Acting Commnm Development Director 17 CITY OF SANTA ANA g IIA K TZ J( City Manager SUBRECIPIENT: qgz-- NOe:'Rr,berh91mana Title: Chief Executive Officer Tax ID: 95-1893417 DUNS #: 03-060-3781 City of Santa Ana CDBG Scope of Work Program Year 2017-18 (July 1, 2017 -June 30, 2018) Name of Organization Boys & Girls Club of Central Orange Coast Name of Funded Program College Bound - Santa Ana Sites Annual Accomplishment Goal Unduplicated Participants anticipated to be served during the 12 -month contract period. 75 TOTAL J 1 75 Santa Ana Participants 1 100% 1 60 Low Income Participants 80% Program and Funding Description a. In College Bound, Academic Advisors provide the regular tutoring, academic advising, and other tactical support needed to help teens understand, undertake, and succeed in college application and matriculation. Advisors track students' A -G high school graduation requirements to make sure they are on track to attend UC/CSU, understand application and testing procedures, identify financial aid opportunities and commitments made to attend college, and manage other deadlines associated with college attendance. All College Bound students are introduced to opportunities beyond four year institutions: community college, trade schools, military, and other alternatives. College Bound teens have access to resources and tutors that focus on academics and provide homework and SAT/PSAT assistance. Advisors also maintain an extensive list of scholarships and grants with deadlines and requirements, matching students to appropriate opportunities, and we provide FAFSA and scholarship workshops and application assistance to help them secure financial resources. For first -generation college students, whose families are often unfamiliar with the college application process, these services demystify the process of applying for admission and make college an attainable goal. b. Services are offered five days a week, year -around. c. The case management component of College Bound involves one-on-one support between the teens and Academic Advisors. We supplement academic learning with weekly workshops on college requirements, writing skills, SAT preparation, resume writing, and other topics; we also offer college tours, field trips, and motivational guest speakers. Another role of the Academic Advisors is to meet and counsel parents to inform them about the process and costs associated with College, the value of earning an advanced degree, and engaging them in their child's educational journey. d. The majority of the students we serve are typically low-income students ages 13-18 at our main Club Garage Teen Center site and partner sites at Santa Ana High School (520 W. Walnut St, Santa Ana, CA 92701), Saddleback High School (2802 S. Flower St., Santa Ana, CA 92707), Samuel! Academy (1901 N. Fairview St, Santa Ana, CA 92706), NOVA Academy (500 W. Santa Ana Blvd, Santa Ana, CA 92701). 97% of participants are Latina/o. Taken together, our individualized case management approach helps at - risk teens stay on track through high school and plan for a successful future. Schedule of Performance Quarter 1: JUL 1 - SEP 30 Quarter 2: OCT 1 - DEC 31 Quarter 3: JAN 1 - MAR 31 Quarter 4: APR 1 - JUN 30 Unduplicated Estimated Participants Invoicing 20 $ 17,090 15 $ 11,850 25 $ 16,311 15 $ 16,581 75 $ 61,832 Exhibit A Page 1 of 1 Santa Ana CDBG Program Budget Program Year 2017-2018 Organization Name Boys & Girls Club of Central Orange Coast Program Name College Bound - Santa Ana Sites Expenditures Category Expenses Funded by Santa Ana CDBG Expenses Funded by Other Sources Individual Contributions Total Program Budget Total Organizational Budget Administrative Staff Salaries & Benefits $ 25,000 $ 10,289.00 $ 10,289 $ 641,079 Program Staff Salaries & Benefits $ 61,832 $ 175,560 $ 237,392 $ 2,733,018 Contractual/Professional Services $ - $ - $ - $ 250,690 Supplies $ - $ 15,000 $ 15,000 $ 374,165 Scholarships $ - $ 45,000 $ 45,000 $ 61,600 College Test Prep $ - $ 9,000 $ 9,000 $ 1,100 Application Assistance $ - $ 5,400 $ 5,400 $ 7,700 College Field Trips $ - $ 18,000 $ 18,000 $ 22,000 Occupation and Transportation $ - $ 464,894 Other Organizational Expenses $ - $ 185,854 Total Direct Costs $ 61,832 TOTAL DIRECT COSTS $ 61,832 $ 278,249 $ 340,081 $ 4,742,100 0% RATE $ - $ - $ - Total $ 61,832 $ 278,249 $ 340,081 $ 4,742,100 Indirect cost rate: 0% Federaly negotiated indirect cost rate, see documentation in Exhibit B-2 LIST ALL OTHER PROGRAM FUNDS THAT HAVE BEEN SECURED FOR 16-17 (Total Funds for Program must equal Total Program Budget above) Source Amount Santa Ana CDBG $ 61,832 Individual Contributions $ 75,000 Special Events $ 25,000 Foundations/Trusts $ 178,249 Program Fees $ - Total Funds for the Program $ 340,081 Program Year 2017-18 CDBG Funded Personnel Name of Organization: Boys & Girls Club of Central Orange Coast Name of Program College Bound - Santa Ana Sites NOTE: Reimbursement will be based off of actual service and documented expenditures. PROGRAM SPARK Position Title Annual Salary Annual Benefits Total Compensation CDBG Furids Requested for this position College Bound Director $ 55,000 $ 55,000 $ 6,250 Academic Advisors (4) $ 75,000 $ 75,000 $ 55,582 $ Total Amount Requestedl $ 61,832 Must equal amount indicated on Exhibit B CONTRACTi1AUPRORESSIONAL SERVICES Type of Service Annual Contract Amount Total Compensation CDBG Funds Requested Total Amount Requested $ - Budget Narrative Budget Narrative- Describe line items Listed in the budget. Item: Description Must equal amount indicated on Exhibit B College Bound Director Lead program staff that manages individual acamademic cases at Garage Teen Center and oversees program Academic Advisors (4) Program staff that advise and support teens in program ExhibitB-1 Page 1 of 1 Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The regulations were published as Part VII of the May 26,1988 Federal Register (pages 19160-19211). (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION - Attached) (1) The prospective recipient of federal assistance funds certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. (2) Where the prospective recipient of federal assistance funds is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Rob.�Y+ ;;6, -�V C.M Name and Title of Authorized Representative Signature .-' / ' Date EXHIBIT C Page 1 of 2 INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective recipient of federal assistance funds is providing the certification as set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is 'later determined that the prospective recipient of federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department of Labor (DOL) may pursue available remedies, including suspension and/or debarment. 3. The prospective recipient of federal assistance funds shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective recipient of federal assistance funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms 'covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. The prospective recipient of federal assistance funds agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the DOL. 6. The prospective recipient of federal assistance funds further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and voluntary exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to check the List of Parties Excluded from Procurement or Non - Procurement Programs. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction lmowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the DOL may pursue available remedies, including suspension and/or debarment. EXHIBIT C Page 2 of 2 Certification Regarding Lobbying Certification for Contracts, Grants, Loans, and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contact, grant, loan or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, 'Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontract, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed. when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U. S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. UOYS c E iacF CE,�S or— Ca Y70f, 0(1Awt— C`G7A� T- cOi °� aWvb Grantee/Contactor Organization Program Title Name of Certifying Officer EXHIBIT D Page 1 of 2 7—r Li - Date SUBRECIPIENT warrants the following 1. SUBRECIPIENT will comply with Public Law 88-352, Title VI of the Civil Rights Act of 1964 (42 U. S. C. section 2000 et seq.) and implementing regulation in 24 CFR Part 1. 2. No person in the United States shall on the ground of race, color, religion, national origin, or sex, be excluded from participation in, or be denied the benefits of, or be subjected to discrimination tinder any program or activity funded in whole or in part with community development funds made available pursuant to the ACT. 3. All laborers and mechanics, employed by contractors or subcontractors in the performance of construction work financed in whole or in part with community development funds shall be paid wages at rates not less than those prevailing on similar construction in the locality as determined in accordance with the Davis -Bacon Act, as amended, 40 U. S. C. Sections 276 a 1-5, except for individuals who perform services for which they volunteered; do not receive compensation for such services; or are paid expenses, reasonable benefits, or a nominal fee for such services; and are not otherwise employed at any time in construction work. 4. SUBRECIPIENT will comply with all Federal statutes applicable to projects funded with community development funds, except that (a) SUBRECIPIENT does not assume CITY'S environmental responsibilities described at 24 CFR 570.604; and (b) SUBRECIPIENT does not assume CITY'S responsibility for initiating the review process under Executive Order 12372. EXHIBIT D Page 2 of 2 Certification Regarding Drug -Free Workplace Requirements The certification set out below is a material representation upon which reliance is placed by the U.S. Department of Housing and Urban Development in awarding the grant. If it is later determined that the contractor knowingly rendered a false certification, or otherwise violates the requirements of the Drug -Free Workplace Act, the U.S. Department of Housing and Urban Development, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug -Free Workplace Act. CERTIFICATION A. The contractor certifies that it will provide a drug-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture distribution, dispensing, possession or use of a controlled substance is prohibited in the contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing a drug-free awareness program to inform employees about — (1) The dangers of drug abuse in the workplace; (2) The contractor's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee who will be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph -(a) that, as a condition of employment under the contract, the employee will - (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction. (e) Notifying the U.S. Department of Housing and Urban Development within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; EXHIBIT E Page 1 of 3 (f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted - ( 1) Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). B. The contractor shall insert in the space provided on the attached "Place of Performance' form the site(s) for the performance of work to be carried out with the grant funds (including street address, city, county, state, and zip code) .the contractor further certifies that, if it is subsequently determined that additional sites will be used for the performance of work under the contract, it shall notify the U.S. Department of Housing and Urban Development immediately upon the decision to use such additional sites by submitting a revised "Place of Performance" form. >' 6,P7 -L5 CL ARS 0-r CCYV Y2V9C W.y` C -GT COYI,a7 Organization Au h ��ature Date EXHIBIT E Page 2 of 3 PLACE OF PERFORMANCE FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Name: Sys 4 G -f2 GF' < EEN dz,1z. 02 c c�gs'r- Date: 0 __? -r V -I'? The Contractor shall insert in the space provided below the site(s) expected to be used for the performance of work under the contract covered by the certification: Place of Performance (include street address, city, county, state, zip code for each site): 9 Vi t -k' & I As D S7- . S"+,17 -A 14�IA cp 92703 EXHIBIT E Page 3 of 3 A D® CERTIFICATE OF LIABILITY INSURANCE Y) D7/12/2017 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(les) 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 Hays Companies 4200 Concours, Suite #350 Ontario CA 91764 CONTACT Nilda Garcia NAME: (909)243-8111 JO No: -MAIL V�a�.ia@hayscompanies.com scorn anies.com ADDRESS: g y P MESE INSURERS AFFORDING COVERAGE NAIC N INSURERA:Great American Ins. Co. of NY 22136 INSURED Boys & Girls Clubs of Central Orange Coast 250 N Golden Circle Suite 104 Santa Ana CA 92705 INSURER B:Insnrance Company of the West 27847 INSURERC: INSURERD: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:CL1752540536 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 ADDLSUBR POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDIYI'YY LIMITS Santa Ana, CA 92702-1988 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE In 1,000,000 ACL-NMS-MADE1XI DAMAGE TO RENTED 100,000 PREMISES Eaoccurrence $ X MED ERE (Any one person) $ 5,000 Professional Liabilty X PAC4614128 2/11/2017 2/11/2018 X Sexual Misconduct PERSONAL& ADV INJURY s 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 X POLICY ❑LOC PRODUCTS - COMP/OP AGO $ 3,000,000 SEXUAL ABUSE COV $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLELIMIT _$_1000'000 Ea accident BODILY INJURY (Per person) $ A X ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS CA24614129 2/11/2017 2/11/2018 BODILY INJURY(Peraccident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Peraccident Medical Payments $ 5,000 X UMBRELLA ILIAD OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ A EXCESSLIAB CLAIMS -MADE DED X RETENTION$ 10,000 $ 131,184614130 2/11/2017 2/11/2018 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE X PER 'ER'_ STATUTE ER E.L. EACH ACCIDENT $ 1 000 000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, tleecdo. under WVE 5033839 02 6/1/2017 6/1/2018 E. L. DISEASE - EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E, L. DISEASE -POLICY LIMIT $ 1,000,000 A Property R/C: Spcl Form E PAC4614128 2/11/2017 2/11/2018 Blanket BPP',$876,000 Deductible', $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) *30 days Notice of Cancellation except 10 days for non-payment; City of Santa Ana Community Development Agency, its officers, agents, employees, and volunteers are Additional Insureds; Primary & Non-contributory applies to the cert. holder; CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) INS025 PJn14n11 © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Community Development Agency ACCORDANCE WITH THE POLICY PROVISIONS. (M-25) AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702-1988 _ W Mershon/NGARCI ACORD 25 (2014/01) INS025 PJn14n11 © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C *S1*02/20/17*PAC4614128-03*485927922 * D / B * ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY CG 89 70 (Ed. 11/14) THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. SIGNATURE GENERAL LIABILITY BROADENING ENDORSEMENT This Endorsement modifies and is subject to the insurance provided under the following form: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following extension only applies in the event that no other specific coverage for the indicated loss exposure is provided under this Policy. If other specific coverage applies, the terms, conditions and limits of that Coverage are the exclusive coverage applicable under this Policy, unless otherwise noted in this Endorsement. This is a summary of the various additional coverages and coverage modifications provided by this Endorsement. For complete details on specific coverages, consult the actual policy wording. Coverage Description Limit of Insurance Page Non -Owned Aircraft Included 2 Non -Owned Watercraft Included 2 Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Included 3 Medical Payments $ 20,000 3 Damage to Premises Rented to You $ 1,000,000 3 Supplementary Payments - Bail Bonds $ 3,000 4 Supplementary Payments - Loss of Earnings $ 1,000 per day 4 Newly Formed or Acquired Organizations Included 4 Unintentional Failure to Disclose Hazards Included 5 Knowledge of Occurrence, Claim or Suit Included 5 Property Damage Liability - Elevators Included 5 Property Damage Liability - Borrowed Equipment Included 5 Liberalization Clause Included 6 Amendment of Pollution Exclusion (Premises) Included 6 Limited Property Damage to Property of Others $ 5,000 6 Additional Insured - Manager or Lessor of Premises Included 7 CG 89 70 (Ed. 11/14) (Page 1 of 12) C *S1*02/20/17*PAC 4614128-03*485927922 *D/B* ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY Coverage Description Limit of Insurance Page Additional Insured - Funding Sources Included 7 Additional Insured - By Contract Included 8 Primary and Non -Contributory Additional Insured Extension Included 10 Additional Insureds - Protection of Your Limits Included 10 Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Included 11 Property Damage Extension With Voluntary Payments $ 1,000/$ 5,000 11 Who Is An Insured - Fellow Employee Extension - Management Employees Included 12 Broadened Personal and Advertising Injury Included 12 A. Non -Owned Aircraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, exclusion g. Aircraft, Auto or Watercraft does not apply to an aircraft provided: 1. it is not owned by any insured; 2. it is hired, chartered or loaned with a trained paid crew; 3, the pilot in command holds a currently effective certificate, issued by the duly. constituted authority of the United States of America or Canada, designating him or her a commercial or airline pilot; and 4. it is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the Insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this Policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. Non -Owned Watercraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (2) of exclusion g. Aircraft, Auto or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) less than 60 feet long; and CG 89 70 (Ed. 11/14) (Page 2 of 12) C "51"02/20/17"PAC4614128-03"465927922 "0/B` ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY (b) not being used to carry persons or property for a charge. C. Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Under SECTION V - DEFINITIONS, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness, or disease, including death of a person. "Bodily Injury" also means mental injury, mental anguish, humiliation, or shock if directly resulting from physical injury, sickness, or disease to that person. D. Medical Payments If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this Policy are amended as follows: The Medical Expense Limit in paragraph 7, of SECTION III - LIMITS OF INSURANCE is replaced by the following Medical expense Limit: The Medical Expense Limit provided by this Policy shall be the greater of: a. $20,000; or b. the amount shown in the Declarations for Medical Expense Limit This provision 7. is subject to all the terms of SECTION III - LIMITS OF INSURANCE. E. Damage to Premises Rented to You If Damage to Premises Rented to You is not otherwise excluded from this Coverage Part: 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: 3. The last paragraph of paragraph 2. Exclusions is deleted in its entirety and replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water to premises while rented to you or temporarily occupied by you with permission of the owner. A separate Limit of Insurance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE. However, this insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with the permission of the owner, caused by: I. rupture, bursting, or operation of pressure relief devices; ii. rupture or bursting due to expansion or swelling of the contents of any building or structure, caused by or resulting from water; iii, explosion of steam boilers, steam pipes, steam engines, or steam turbines; or iv. flood 2. Paragraph 6. Under SECTION III - LIMITS OF INSURANCE is deleted in its entirety and replaced with the following: CG 89 70 (Ed. 11/14) (Page 3 of 12) C *S1*02/20/17*PAC 4614128-03*485927922 * D / B * ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY 6. Subject to paragraph 5. above, the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection system or water while rented to you or temporarily occupied by you with the permission of the owner, for all such damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water or any combination of the six, is the higher of $ 1,000,000 or the amount shown in the Declarations for the Damage to Premises Rented to You Limit. 3. Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, subsection 4. Other Insurance, paragraph b. Excess Insurance where the words "Fire insurance" appear they are changed to "insurance for fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water." 4. As regards coverage provided by this provision I. Damage to Premises Rented to You - paragraph 9.a. of Definitions is replaced with the following: 9, a. a contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water to premises while rented to you or temporarily occupied by you with the permission of the owner is not an "insured contract"; F. Supplementary Payments 1. In the Supplementary Payments - Coverages A and B provision, paragraph 1.b, is replaced with: - b. Up to $ 3,000 for the cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following; d. All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $ 1,000 a day because of time off work. G. Newly Formed or Acquired Organizations Paragraph 3. of SECTION II - WHO IS AN INSURED is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a named insured if there is no other similar insurance available to that organization. However: a. coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. coverage A does not apply to "bodily injury" or property damage that occurred before you acquired or formed the organization; and c. coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. CG 89 70 (Ed. 11/14) (Page 4 of 12) C "S 1'02/20/17"PAC 4614128-03"485927922 "D/B* ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY d. records and descriptions of operations must be maintained by the first named insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a named insured in the Declarations or qualifies as an insured under this provision. H. Unintentional Failure to Disclose Hazards Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 6. Representations: Failure of the Insured to disclose all hazards existing as of the inception date of this Policy shall not prejudice the insurance with respect to the coverage afforded by this Policy, provided such failure or omission is not intentional on the part of the Insured. I. Knowledge of Occurrence, Claim or Suit Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: Knowledge of any occurrence, claim, or suit by any agent, servant or employee of the Named Insured does not in itself constitute knowledge by the Insured unless notice of such injury, claim or suit shall have been received by: a. you, if you are an individual; b, a partner, if you are a partnership c. an executive officer or insurance manager, if you are a corporation. J. Property Damage Liability - Elevators 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraphs (3), (4) and (6) of exclusion j. Damage to Property do not apply if such property damage results from the use of elevators. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. K. Property Damage Liability - Borrowed Equipment 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (4) of exclusion j. Damage to Property does not apply to .,property damage" to borrowed equipment while not being used to perform operations at a job site. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY Conditions, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. CG 89 70 (Ed. 11/14) (Page 5 of 12) C *51*02/20117*PAC4614128-03*485927922 *D/B* ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY L. Liberalization Clause If we revise this Signature General Liability Broadening Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the date the revision is effective in your state. M. Amendment of Pollution Exclusion (Premises) 1. The following is added to paragraph (1)(a) of Exclusion f. of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: (iv) 'Bodily injury" or "property damage" arising out of the actual discharge, dispersal, seepage, migration, release or escape of "pollutants." As used in this Endorsement, the actual discharge, dispersal, seepage, migration, release or escape of pollutants must: (aa) commence on a clearly identifiable day during the policy period; and (bb) end, in its entirety, within seventy-two (72) hours of the commencement of the discharge, dispersal, seepage, migration, release or escape of "pollutants"; and (cc) be discovered and reported to us within fifteen (15) days of the clearly identifiable day that the discharge, dispersal, seepage, migration, release or escape of "pollutants" commences; and (dd) be neither expected nor intended from the standpoint of any insured; and (cc) be unrelated to any previous discharge, dispersal, seepage, migration, release or escape; and (ff) not originate at or from a storage tank or other container, duct or piping which: a. is below the surface of the ground or water; or b. at any time has been buried under the surface of the ground or water and then is subsequently exposed. 2. For the purposes of this coverage, the following is added to the definition of "property damage" of SECTION V - DEFINITIONS and applies only as respects this coverage: Land or water, whether below ground level or not, is not tangible property. 3. Coverage provided hereunder does not apply to any discharge, dispersal, seepage, migration, release or escape that is merely threatened or alleged rather than shown to have actually occurred. N. Limited Property Damage to Property of Others The following is added under SECTION I - SUPPLEMENTARY PAYMENTS - COVERAGES A and B: 3. We will pay up to $ 5,000 for loss to personal property of others while in the temporary care, custody or control of an insured caused by any person participating in your organized activities. For the purpose of this supplementary payment, loss shall mean damage or destruction but does not include mysterious disappearance or loss of use. In the event of a theft, a police report must be filed. This supplementary payment does not apply if: a. coverage is otherwise provided by the Property Coverage part (if any) of this Policy; or CG 89 70 (Ed. 11114) (Page 6 of 12) C *S1"02/20!17*PAC4614128-03*485927922 *D/B* ORIG IMAGE COPY 0253663 GREAT AMERICAN INS CO OF NY b. the loss is covered by any other insurance you have or by any insurance of such person who causes such loss. These payments will not reduce the Limits of Insurance. O. Additional Insured - Manager or Lessor of Premises 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any person or organization from wham you lease or rent property and which requires you to add such person or organization as an additional insured on this Policy under: (a) a written contract; or (b) an oral agreement or contract where a Certificate of Insurance showing that person or organization as an additional insured has been issued; but the written or oral contract or agreement must be an "insured contract," and, (i) currently in effect or become effective during the term of this Policy; and (ii) executed prior to the "bodily injury," "property damage," "personal and advertising injury." 2. With respect to the insurance afforded to the Additional Insured identified in paragraph 1, above, the following additional provisions apply: (a) This insurance applies only with respect to the liability arising out of the ownership, maintenance or use of that part of the premises [eased to you. (b) The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. (c) In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. (d) Coverage provided herein is excess over any other valid and collectible insurance available to the Additional Insured whether the other insurance is primary, excess, contingent or on any other basis unless a written contractual arrangement specifically requires this insurance to be primary, (e) This insurance applies only to the extent permitted by law. 3. This insurance does not apply to: (a) Any "occurrence" or offense which takes place after you cease to be a tenant in that premises. (b) Structural alterations, new construction or demolition operations performed by or on behalf of the Additional Insured. P. Additional Insured - Funding Sources 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any Funding Source which requires you in a written contract to name the Funding Source as an additional insured but only with respect to liability arising out of: CG 89 70 (Ed. 11/14) (Page 7 of 12) C "S1"02/20/17"PAC4614128-03"485927922 "D/B` ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY a. your premises; or b. "your work" for such additional insured; or c, acts or omissions of such additional insured in connection with the general supervision of "your work" and only to the extent set forth as follows: a. The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. b. The insurance afforded to the Additional Insured only applies to the extent permitted by law c. 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. d. In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. Q. Additional Insureds - By Contract 1. SECTION II - WHO IS AN INSURED is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of: a. your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the Additional Insured that are subject of the written contract or written agreement provided that the "bodily injury" or "property damage occurs, or the "personal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or b. the maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or c. the Additional Insureds financial control of you; or d. operations performed by you or on your behalf for which the state or political subdivision has issued a permit However: 1. 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 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 Such additional insured. With respect to paragraph 1.a, above, a person's or organization's status as an additional insured under this Endorsement ends when: CG 89 70 (Ed. 11/14) (Page 8 of 12) C *S1*02/20/17*PAC4614128-03*485927922 *D/B* ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to paragraph 1.b. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this Endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage." We have no duty to defend an additional insured under this Endorsement until we receive written notice of a "suit" by the Additional Insured as required in paragraph b. of Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITION. 2. With respect to the insurance provided by this Endorsement, the following are added to paragraph 2. Exclusions under SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" that occurs prior to your commencing operations at the location where such "bodily injury" or "property damage" occurs. b. "Bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services, including: (1) the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) supervisory, inspection, architectural or engineering activities, This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "property damage," or the offense which caused the "personal and advertising injury," involved the rendering of, or failure to render, any professional architectural, engineering or surveying services. c. 'Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of 'your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 89 70 (Ed. 11/14) (Page 9 of 12) C "S1`02/20/17"PAC4614128-03"485927922 "D/B" ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY d. Any person or organization specifically designated as an additional insured for ongoing operations by a separate additional insured endorsement issued by us and made part of this Policy. 3. 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 of insurance: a, required by the contract or agreement; or b. 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. R. Primary and Non -Contributory Additional Insured Extension This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to paragraph a. Primary Insurance: This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) the Additional Insured is a named insured under such other insurance; and (2) you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the Additional Insured. b. The following is added to paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement or permit issued by a state or political subdivision between you and an additional Insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the Additional Insured is designated as a named insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the Additional Insured has been added as an additional insured on other policies. S. Additional Insureds - Protection of Your Limits This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. 1. The following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: An additional insured under this Endorsement will as soon as practicable: CG 89 70 (Ed. 11/14) (Page 10 of 12) C 'S1*02/20/17"PAC4614128-03"485927922 "D/B" ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY a. give written notice of an 'occurrence" or an offense that may result in a claim or "suit' under this insurance to us; b. tender the defense and indemnity of any claim or "suit' to all insurers whom also have insurance available to the Additional Insured; and c. agree to make available any other insurance which the Additional Insured has for a loss we cover under this Coverage Part. d. we have no duty to defend or indemnify an additional insured under this Endorsement until we receive written notice of a "suit' by the Additional Insured. 2. The Limits of Insurance applicable to the Additional Insured are those specified in a written contract or written agreement or the Limits of Insurance stated in the Declarations of this Policy and defined in SECTION III - LIMITS OF INSURANCE of this Policy, whichever are less. These limits are inclusive of and not in addition to the Limits of Insurance available under this Policy. T. Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 8. Transfer of Rights of Recovery Against Others to Us: If required by a written contract or written agreement, we waive any right of recovery we may have against a person or organization because of payment we make for injury or damage arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products -completed operations hazard" provided that the injury or damage occurs subsequent to the execution of the written contract or written agreement. U. Property Damage Extension with Voluntary Payments 1. The following is added to paragraph 1. Insuring Agreement of SECTION 1 - COVERAGE A - Bodily Injury and Property Damage Liability: At your request we will pay for "loss" to property of others caused by your business operations for which this Policy provides liability insurance. Such payment will be made without regard to your legal obligation to do so. The "loss" must occur during the policy period and must take place in the "coverage territory." 2. With respect to the coverage afforded under paragraph 1. above, paragraph 2. Exclusions of SECTION I - COVERAGES A - Bodily Injury and Property Damage Liability is amended as follows: Exclusions j.(3), j.(4), j.(5) and j.(6) are deleted. 3. As respects coverage afforded by this coverage, SECTION III - LIMITS OF INSURANCE is replaced by the following: Regardless of the number of insureds, claims made or "suits" brought or persons or organizations making claims or bring "suits": 1. Subject to 2. Below, the most we will pay for one or more "loss" arising out of any one "occurrence"is $ 1,000. 2. The aggregate amount we will pay for the sum of all "loss" in an annual period is $ 5,000. This aggregate amount is part of and not in addition to the General Aggregate Limit described in paragraph 2. of SECTION III - LIMITS OF INSURANCE. CG 89 70 (Ed. 11/14) (Page 11 of 12) C "S 1'02/20/17"PAC4614128-03"485927922 °D/B' ORIG IMAGE COPY 0253563 GREAT AMERICAN INS CO OF NY V. Who Is an Insured - Fellow Employee Extension - Management Employees 1. The following is added to paragraph 2.a.(1) of SECTION II - WHO IS AN INSURED: Paragraph (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, including the direct supervision of other "employee" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury," caused in whole or in part by their intoxication by liquor or controlled substances. This coverage is excess over any other valid and collectable insurance available to your "employee." W. Broadened Personal and Advertising Injury 1. Unless "Personal. and Advertising Injury" is excluded from this Policy, the following is added to SECTION V - DEFINITIONS Item 14.: h. mental injury, mental anguish, humiliation, or shock, if directly resulting from Items 14.a. through 14.e. CG 89 70 (Ed. 11/14) (Page 12 of 12) A� O® CERSICATE OF LIABILITY INSURACE DATEtMMIDOIYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 05/23/2018 THIS CERTIFICATE IS ISSUED ASA 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(les) must have ADDITIONAL INSURED provisions or 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 CONTACT Nilda Garcia NAME: Hays Companies PHONE (909)243-8111 FAX AIC Na E#: AIC No: 4200 Concours, Suite #350 E-MAIL scornarc D ia ha antes. Com ADDRESS: g y p INSURERS) AFFORDING COVERAGE NAIC# Ontario CA 91764 INSURERA: Arch Insurance Company 11150 INSURED INSURER B: Cypress Insurance Company 10855 Boys & Gids Clubs of Central Orange Coast INSURER C: 17701 Cowan, Suite Ijo INSURER D: INSURER E: MED UP (Any one person) $ 20,000 Irvine CA 92614 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1852360822 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTH E 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 ADDLSUbK INSD MD POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 1,000,000 E T D 1,000,000 PREMISESDAMAGE Eaoccwrence $ Professional Llabllty - MED UP (Any one person) $ 20,000 X Sexual Misconduct PERSONAL a ADV INJURY $ 1,000,000 A Y AAPKGO028800 02/11/2018 02/11/2919 GEN'LAGGREGAYE LIMITAPPLIES PER: POLICY � JECT LOC GENERALAGGREGATE $ 3,000,000 - - PRODUCTS-COMPIOP AGO $ 3,000,000 SEXUALABUSE COV s 1,000,000 OTHER'. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accitlart BODILY INJURY (Per person) $ ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS AAAUT0028800 02/11/2018 02/11/2019 BODILY NJURY(Peraccidenq $ HIRED NON-ONMEO AUTOS ONLY AUTOS ONLY. - PROPERTY DAMAGE $ Per accident Medical payments $ 5,000,000 UMBRELI-ki OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MAOE AAFXS0028800 02/11/2018 02/11/2019 AGGREGATE 5 DED .RETENTION $ 10,000 s WORKERS COMPENSATION PER OTH- B AND EMPLOYERS' LIABILITYY ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? IMandatmy in NH) If yea, doacnba under DESCRIPTION OF OPERATIONS below NIA BOWC914957 06/01/2018 06/01/2019 STATUTE ER E. L. EACHACCIDENT $ 1,000,000 E.L_. DISEASE -EA $ 1,000,000 E. L. DISEASE -POLICY LIMIT $ 1,000,000 A Property RIC: Spat Form AAPKG0028800 02/11/2018 02/11/2019 - Blanket BPP', $1,011,000 Deductible', $1,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Add ltlanal Remarks Schedule, maybe attached if mare space is required) City of Santa Ana, Community Development Agency is Additional Insured; With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds; Primary & Non -Contributory wording applies, CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Are, Community Development Agency ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza, M-25 AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMEP CHANGES THE POLICY. PLEAIPREAD IT CAREFULLY. SOCIAL SERVICES PREMIER GENERAL LIABILITY ENHANCEMENT ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposures are provided under this policy. If such specific coverage applies, the terms, conditions, and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your" refer to the "Named Insured" shown in the Declarations. The words "we", "us", and "our' refer to the "Company" providing this insurance. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is a summary of the Limits of Insurance and Additional Coverage provided by this endorsement. For complete details on specific coverage's, consult the policy contract wording. A) Medical Payment— Limit increased to $20,000 B) Supplementary Payments — Bail bonds increased to $3,0001 Loss of Earnings increased to $1,000 each day C) Damage to Premises Rented to You — Fire, Lightning, Explosion, Smoke and Leaks from Fire Protective Sprinklers limit increased to $1,000,000 D) Broadened definition of Who is an Insured E) Knowledge or Notice of Occurrence F) Broadened definition of Advertising Injury includes televised, videotaped, or internet-based publication G) Amended definition of Bodily Injury to include mental anguish H) Amended Unintentional Failure to Disclose Hazards 1) Amended Liberalization Clause J) Property Damage — Removal of exclusion for "Property Damage" resulting from the use of reasonable force to protect persons or property K) Premises Sold or Abandoned by You L) Added Blanket Additional Insured - Funding sources M) Added Blanket Additional Insured - Managers or lessors of premises N) Additional Insured — By Contract, Agreement or Permit O) General Aggregate Limit Per Location P) Blanket Special Events and Fund Raising Events Coverage Q) Non -Owned Watercraft Coverage - Length is increased to 65 feet R) Blanket Waiver of Subrogation S) Waiver of Immunity T) Violation of Rights of Residents Coverage (Patient's Rights) U) Liquor Liability Exception to Exclusion V) Employee Criminal Defense Coverage - $25,000 limit A) MEDICAL PAYMENTS If Medical Payments Coverage (Coverage C) is not otherwise excluded from this Coverage Part: 1) The Medical Expense Limit is increased, subject to all the terms of Limits of Insurance (Section III) to $20,000 2) The requirement in the Insuring Agreement of Coverage C, that expenses must be incurred and reported to us within "one year" of the accident date is changed to "three years." B) SUPPLEMENTARY PAYMENTS Coverage A. and B. provisions: 1) The limit for the cost of bail bonds is changed from $250 to $3,000. 2) The limit for loss of earnings is changed from $250 per day to $1,000 per day. 00 GL0295 00 02 09 Page 1 of 7 Z o,�- 6 0 0 C) DAMAGE TO PREMISES RENTED TO YOU If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" and the words "fire insurance" are changed to "fire, lightning, explosion, smoke, or leakage from fire protective sprinklers" where it appears in: 1) The last paragraph of Section I — Coverages, Coverage A Bodily Injury And Property Damage Liability, subsection 2. Exclusions; 2) Section III Limits Of Insurance, paragraph 6.; 3) Section V — Definitions, paragraph 9.a. 4) Section IV — Commercial General Liability Conditions, subsection 4. Other Insurance, paragraph b. Excess Insurance The Damage to Premises Rented to You Limit section of the Declarations is amended to $1,000,000. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke or leakage from fire protective sprinklers or any combination thereof. D) WHO IS AN INSURED ' Paragraph 2. of Section II — Who Is An Insured is deleted and replaced by the following: 2. Each of the following is also an insured: but only while working within the scope of their duties for the insured: a. (i) "Employees"; (ii) "Volunteer Workers"; (iii) Independent Contractors However, no "employees", "volunteer workers" or independent contractors are insureds for: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership orjoint venture), to your members (if you are al limited liability company), to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker' as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (2) "Property damage" to property: (a) Owned, occupied or used by, (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you.are a partnership or joint venture), or any member (if you are a limited liability company). b. Medical directors and administrators, including professional persons, are also insureds; c. If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds; d. If you are a limited liability company your members are insureds, but only with respect to their duties related to the conduct of your business; e. Any organization and subsidiary thereof which you control and actively manage on the effective date of this endorsement; h" 1114 00 GL0295 00 02 09 Page 2 of 7 se rvl> 0 0 f. Any person or organization that has financial control of you or owns, maintains or controls premises occupied by you and requires you to name them as an additional insured but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. g. Any state or political subdivision subject to the following provision: This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: (1) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar exposures; or (2) The construction, erection, or removal of elevators; or (3) The ownership, maintenance, or use of any elevators covered by this insurance. However, the insurance afforded for any organization and subsidiary thereof not named in the Declarations as a Named Insured, does not apply to injury or damage with respect to which an insured under this endorsement is also an insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. h. Students in training, but not for "bodily injury' or "property damage" arising out of his or her rendering or failure to render professional services to patients; i. Your members but only with respect to their liability for your activities or activities they perform on your behalf; j. Your trustees or members of the board of governors while acting within the scope of their duties as such on your behalf; k. Any entity you are required in a written contract (hereinafter called Additional Insured) to name as an insured is an insured but only with respect to liability arising out of your premises, "your work" for the Additional Insured, or acts or omissions of the Additional Insured in connection with the general supervision of "your work" to the extent set forth below: Insurance does not apply to "bodily injury," "property damage' or "personal and advertising injury" arising out of the rendering or failure to render any professional services by or for you, including but not limited to: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifications; and (2) Supervisors, inspection, or engineering services. Any coverage provided under this provision shall be excess over any other valid and collectible insurance available to the Additional Insured(s) whether primary, excess, contingent or on any other basis unless a contract specifically requires that this insurance be primary or you request that it apply on a primary basis. Paragraph 3a. of Section II — Who Is An Insured is deleted and replaced by the following: a. Coverage under this provision is, subject to (1) and (2) below: (1) Effective on the acquisition or formation date; and (2) Afforded only until the end of the policy period. E) KNOWLEDGE OR NOTICE OF OCCURRENCE 1) As respects any loss reporting requirements under this policy, it is understood and agreed that knowledge of an "occurrence" by an agent, servant or employee of yours or any other person shall not in itself constitute knowledge by you, unless a corporate officer of yours shall have received notice from said agent, servant, employee or any other person. 00 GL0295 00 02 09 Page 3 of 7en-,t 0 2) Your failure to give first report of an "occurrence" to us shall not invalidate coverage under this policy if the loss was inadvertently reported to another insurer. However, you shall report any such "occurrence" to us within a reasonable time once you become aware of such error. F) ADVERTISING INJURY—TELEVISED, VIDEOTAPED, OR INTERNET -BASED PUBLICATION 1) The definition of "Personal and Advertising Injury' item 14. is changed to read: "Personal and Advertising Injury" means injury arising out of one or more of the following offenses: d) Oral, written, televised, videotaped, or internet-based publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products, or services: e) Oral, written, televised, videotaped, or internet-based publication of material that violates a person's right of privacy; f) Misappropriation of advertising ideas or style of doing business; or g) Infringement of copyright, title, or slogan. 2) Exclusions band c. of Coverage B., Personal and Advertising Injury Liability, are changed to read: a) (2) Arising out of oral, written, televised, videotaped, or internet-based publication of material, if done by or at the direction of the insured with knowledge of its falsity; b) (3) Arising out of oral, written, televised, videotaped, or internet-based publication of material whose first publication took place before the beginning of the policy period. G) BODILY INJURY— MENTAL ANGUISH The definition of "bodily injury" is changed to read: "Bodily Injury": a) Bodily injury, sickness, or disease sustained by a person, and includes mental anguish resulting from any of these; and b) Except for mental anguish,' includes death resulting from the foregoing (item a. above) at any time. H) UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. LIBERALIZATION If we adopt a change in our forms or rules which would broaden your coverage without an additional premium charge, your policy will automatically provide the additional coverage(s) as of the date the revision is effective in your state. J) EXTENDED "PROPERTY DAMAGE" SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions a. is deleted and replaced by the following: 1) Expected or Intended Injury; "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage' resulting from the use of reasonable force to protect persons or property. K) PREMISES SOLD OR ABANDONED BY YOU SECTION I -COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, Exclusion j. is amended as follows: Paragraph (2) is replaced by the following: (2) Premises you sell, give away, or abandon, if the "property damage" arises out of any part of �y those premises and occurred from hazards that were known by you or should have reasonably been known by you, at the time the property was transferred or abandoned. 00 GL0295 00 02 09 Page 4 ofr7 rr o� ADDITIONAL INSURED — FUNDING SOURCE Under SECTION II — WHO IS AN INSURED the following is added: OL) : 2) Any person or organization with respect to their liability arising out of: a) Their financial control of you; or b) Premises they own, maintain, or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction, and demolition operations performed by or for that person or organization. M) ADDITIONAL INSURED — MANAGERS OR LESSORS OF PREMISES Under SECTION II —WHO IS AN INSURED the following is added: 1.f. Any person or organization with respect to their liability arising out of the ownership, maintenance, or use of that part of the premises leased to you, subject to the following additional exclusions: This insurance does not apply to: a) Any "occurrence" which takes place after you cease to be a tenant in that premises. b) Structural alteration, new construction, or demolition operations performed by or on behalf of that person or organization. N) ADDITIONAL'INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT 1) Any person or organization is an insured with whom you are required to add as an additional insured to this policy by a written contract or written agreement, or permit that is: a) currently in effect or becoming effective during the term of this policy; and b) executed prior to the "bodily injury," "property damage," "personal and advertising injury". 2) This insurance provided to the additional insured by this endorsement applies as follows: a) That person or organization is only an additional insured with respect to liability caused by your negligent acts or omissions at or from: (1) Premises you own, rent, lease, or occupy, or (2) Your ongoing operations performed for the additional insured at the job indicated by written contract or written agreement. b) The limits of insurance applicable to the additional insured are those specified in the written contract or written agreement or in the Declarations of this policy whichever is less. These limits of insurance are inclusive of and not in addition to the limits of insurance shown in the Declarations. 3) With respect to the insurance afforded these additional insured's, the following additional exclusions apply: a) This insurance does not apply to "Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment.furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations on or at the same project. b) This insurance does not apply to "bodily injury," "property damage," "personal and advertising injury" caused by the rendering of or failure to render any professional services. 4) Regardless of whether other insurance is available to an additional insured on a primary basis, this insurance will be primary and noncontributory if a written contract between you and the additional insured specifically requires that this insurance be primary. 00 GL0295 00 02 09 Page 5 of 7 ��is O) GENERAL AGGREGATE LIMIT PER LOCATION SECTION III — LIMITS OF INSURANCE, is amended as follows: 2. The General Aggregate Limit is the most we will pay for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage' included in the "products -completed operations hazard, and C. Damages under Coverage B. A separate Location General Aggregate Limit applies to each 'location' and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. SECTION V - DEFINITIONS is amended by adding the following: 23. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. P) BLANKET SPECIAL EVENTS AND FUND RAISING EVENTS 1) This insurance applies to your legal liability for "bodily injury," "property damage," and "personal and advertising injury" arising out of all your managed, operated or sponsored special events WITH THE FOLLOWING EXCEPTIONS: a) Events involving aircraft b) Events involving automobile or motorcycle races or rallies C) Events involving fireworks d) Events involving firearms e) Events involving live animals, excluding domestic pets f) Carnivals and fairs with mechanical rides g) Any event lasting more than three (3) days (including otherwise acceptable events) h) Any event with greater than 1,000 people in attendance (including otherwise acceptable events) Coverage may be provided by endorsement issued by us.and made part of this Coverage Part, and subject to an additional premium charge. Q) NON -OWNED WATERCRAFT SECTION I —COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, paragraph g.(2) is amended to read as follows: (2) A watercraft you do not own that is: a) Less than 65 feet long, and b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess, or contingent. R) WAIVER OF SUBROGATION We will waive our right of subrogation in the event of a loss. We must be advised in writing, prior to the loss, of your intention to waive subrogation. We also must know whom subrogation will be waived against. If your request meets our underwriting criteria regarding such waivers, we will waive our right. However, we reserve the right to charge additional premium or to limit the terms and conditions of such waiver. S) WAIVER OF IMMUNITY We will waive, both in the adjustment of claims and in defense of "suits" against the insured, any charitable or governmental immunity of the insured, unless the insured requests, in writing, that we not do so. Waiver of immunity, as a defense, will not subject us to liability for any portion of a claim or judgment, in excess, of the applicable limit of insurance. T) VIOLATION OF RIGHTS OF RESIDENTS (PATIENT'S RIGHTS) 00 GL0295 00 02 09 Page 6 of 7 1) The followingtadded to SECTION 1 — COVERAGES CO4ERAGE A BODILY INJURY AND PROPERTY DAMAGE — paragraph 1. Insuring Agreement: "Bodily Injury" damages arising out of the violation of "Rights of Residents," shall be deemed an "occurrence." 2) As respects the coverage provided in paragraph A.I. of this endorsement, the following exclusions are added to SECTION I — COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE — 2. Exclusions: This insurance does not apply to: a) Liability arising out of the willful or intentional violation of "Rights of Residents." b) Fines or penalties assessed by a court or regulatory authority. C) Liability arising out of any act or omission in the furnishing, or failure to furnish, professional services in the medical treatment of residents. 3) As respects the violation of "Rights of Residents" Coverage, the following definition is added to SECTION V - DEFINITIONS: 24. "Rights of Residents" means: a. Any right granted to a resident under any state law regulating your business as a health care facility. b. The "Rights of Residents' as included in the United States Department of Health and Welfare regulations governing participation of Intermediate Care Facilities and Skilled Nursing Facilities, regardless of whether your facility is ' subject to those regulations. U. LIQUOR LIABILITY EXCLUSION — EXCEPTION FOR SPECIAL EVENTS OR FUNDRAISING EVENTS SECTION 1. COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions c. is amended by adding the following subparagraph: This exclusion does not apply to "bodily injury" or "property damage" arising out of the selling, serving or furnishing of alcoholic beverages at any special events or fundraising events related to the insured's business. V. EMPLOYEE CRIMINAL DEFENSE COVERAGE Under SUPPLEMENTARY PAYMENTS — COVERAGES A AND B, the following is added: 3. We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding. The alleged criminal act must arise out of the "employee's" work performed on your behalf. The most we will pay for any "employee" who is alleged to be directly proceeding is $25,000 regardless of the number of "employees', claims persons or organizations making claims or bringing "suits". All other terms and conditions of this Policy remain unchanged. Endorsement Number: Policy Number: Named Insured: involved in a criminal or "suits" brought or This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 00 GL0295 00 02 09 Page 7 of 7 ,� 00� A� O® CERSICATE OF LIABILITY INSURACE DATEtMMIDOIYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 05/23/2018 THIS CERTIFICATE IS ISSUED ASA 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(les) must have ADDITIONAL INSURED provisions or 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 CONTACT Nilda Garcia NAME: Hays Companies PHONE (909)243-8111 FAX AIC Na E#: AIC No: 4200 Concours, Suite #350 E-MAIL scornarc D ia ha antes. Com ADDRESS: g y p INSURERS) AFFORDING COVERAGE NAIC# Ontario CA 91764 INSURERA: Arch Insurance Company 11150 INSURED INSURER B: Cypress Insurance Company 10855 Boys & Gids Clubs of Central Orange Coast INSURER C: 17701 Cowan, Suite Ijo INSURER D: INSURER E: MED UP (Any one person) $ 20,000 Irvine CA 92614 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1852360822 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTH E 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 ADDLSUbK INSD MD POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 1,000,000 E T D 1,000,000 PREMISESDAMAGE Eaoccwrence $ Professional Llabllty - MED UP (Any one person) $ 20,000 X Sexual Misconduct PERSONAL a ADV INJURY $ 1,000,000 A Y AAPKGO028800 02/11/2018 02/11/2919 GEN'LAGGREGAYE LIMITAPPLIES PER: POLICY � JECT LOC GENERALAGGREGATE $ 3,000,000 - - PRODUCTS-COMPIOP AGO $ 3,000,000 SEXUALABUSE COV s 1,000,000 OTHER'. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accitlart BODILY INJURY (Per person) $ ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS AAAUT0028800 02/11/2018 02/11/2019 BODILY NJURY(Peraccidenq $ HIRED NON-ONMEO AUTOS ONLY AUTOS ONLY. - PROPERTY DAMAGE $ Per accident Medical payments $ 5,000,000 UMBRELI-ki OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MAOE AAFXS0028800 02/11/2018 02/11/2019 AGGREGATE 5 DED .RETENTION $ 10,000 s WORKERS COMPENSATION PER OTH- B AND EMPLOYERS' LIABILITYY ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? IMandatmy in NH) If yea, doacnba under DESCRIPTION OF OPERATIONS below NIA BOWC914957 06/01/2018 06/01/2019 STATUTE ER E. L. EACHACCIDENT $ 1,000,000 E.L_. DISEASE -EA $ 1,000,000 E. L. DISEASE -POLICY LIMIT $ 1,000,000 A Property RIC: Spat Form AAPKG0028800 02/11/2018 02/11/2019 - Blanket BPP', $1,011,000 Deductible', $1,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Add ltlanal Remarks Schedule, maybe attached if mare space is required) City of Santa Ana, Community Development Agency is Additional Insured; With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds; Primary & Non -Contributory wording applies, CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Are, Community Development Agency ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza, M-25 AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMEP CHANGES THE POLICY. PLEAIPREAD IT CAREFULLY. SOCIAL SERVICES PREMIER GENERAL LIABILITY ENHANCEMENT ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposures are provided under this policy. If such specific coverage applies, the terms, conditions, and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your" refer to the "Named Insured" shown in the Declarations. The words "we", "us", and "our' refer to the "Company" providing this insurance. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is a summary of the Limits of Insurance and Additional Coverage provided by this endorsement. For complete details on specific coverage's, consult the policy contract wording. A) Medical Payment— Limit increased to $20,000 B) Supplementary Payments — Bail bonds increased to $3,0001 Loss of Earnings increased to $1,000 each day C) Damage to Premises Rented to You — Fire, Lightning, Explosion, Smoke and Leaks from Fire Protective Sprinklers limit increased to $1,000,000 D) Broadened definition of Who is an Insured E) Knowledge or Notice of Occurrence F) Broadened definition of Advertising Injury includes televised, videotaped, or internet-based publication G) Amended definition of Bodily Injury to include mental anguish H) Amended Unintentional Failure to Disclose Hazards 1) Amended Liberalization Clause J) Property Damage — Removal of exclusion for "Property Damage" resulting from the use of reasonable force to protect persons or property K) Premises Sold or Abandoned by You L) Added Blanket Additional Insured - Funding sources M) Added Blanket Additional Insured - Managers or lessors of premises N) Additional Insured — By Contract, Agreement or Permit O) General Aggregate Limit Per Location P) Blanket Special Events and Fund Raising Events Coverage Q) Non -Owned Watercraft Coverage - Length is increased to 65 feet R) Blanket Waiver of Subrogation S) Waiver of Immunity T) Violation of Rights of Residents Coverage (Patient's Rights) U) Liquor Liability Exception to Exclusion V) Employee Criminal Defense Coverage - $25,000 limit A) MEDICAL PAYMENTS If Medical Payments Coverage (Coverage C) is not otherwise excluded from this Coverage Part: 1) The Medical Expense Limit is increased, subject to all the terms of Limits of Insurance (Section III) to $20,000 2) The requirement in the Insuring Agreement of Coverage C, that expenses must be incurred and reported to us within "one year" of the accident date is changed to "three years." B) SUPPLEMENTARY PAYMENTS Coverage A. and B. provisions: 1) The limit for the cost of bail bonds is changed from $250 to $3,000. 2) The limit for loss of earnings is changed from $250 per day to $1,000 per day. 00 GL0295 00 02 09 Page 1 of 7 Z o,�- 6 0 0 C) DAMAGE TO PREMISES RENTED TO YOU If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" and the words "fire insurance" are changed to "fire, lightning, explosion, smoke, or leakage from fire protective sprinklers" where it appears in: 1) The last paragraph of Section I — Coverages, Coverage A Bodily Injury And Property Damage Liability, subsection 2. Exclusions; 2) Section III Limits Of Insurance, paragraph 6.; 3) Section V — Definitions, paragraph 9.a. 4) Section IV — Commercial General Liability Conditions, subsection 4. Other Insurance, paragraph b. Excess Insurance The Damage to Premises Rented to You Limit section of the Declarations is amended to $1,000,000. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke or leakage from fire protective sprinklers or any combination thereof. D) WHO IS AN INSURED ' Paragraph 2. of Section II — Who Is An Insured is deleted and replaced by the following: 2. Each of the following is also an insured: but only while working within the scope of their duties for the insured: a. (i) "Employees"; (ii) "Volunteer Workers"; (iii) Independent Contractors However, no "employees", "volunteer workers" or independent contractors are insureds for: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership orjoint venture), to your members (if you are al limited liability company), to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker' as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (2) "Property damage" to property: (a) Owned, occupied or used by, (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you.are a partnership or joint venture), or any member (if you are a limited liability company). b. Medical directors and administrators, including professional persons, are also insureds; c. If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds; d. If you are a limited liability company your members are insureds, but only with respect to their duties related to the conduct of your business; e. Any organization and subsidiary thereof which you control and actively manage on the effective date of this endorsement; h" 1114 00 GL0295 00 02 09 Page 2 of 7 se rvl> 0 0 f. Any person or organization that has financial control of you or owns, maintains or controls premises occupied by you and requires you to name them as an additional insured but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. g. Any state or political subdivision subject to the following provision: This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: (1) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar exposures; or (2) The construction, erection, or removal of elevators; or (3) The ownership, maintenance, or use of any elevators covered by this insurance. However, the insurance afforded for any organization and subsidiary thereof not named in the Declarations as a Named Insured, does not apply to injury or damage with respect to which an insured under this endorsement is also an insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. h. Students in training, but not for "bodily injury' or "property damage" arising out of his or her rendering or failure to render professional services to patients; i. Your members but only with respect to their liability for your activities or activities they perform on your behalf; j. Your trustees or members of the board of governors while acting within the scope of their duties as such on your behalf; k. Any entity you are required in a written contract (hereinafter called Additional Insured) to name as an insured is an insured but only with respect to liability arising out of your premises, "your work" for the Additional Insured, or acts or omissions of the Additional Insured in connection with the general supervision of "your work" to the extent set forth below: Insurance does not apply to "bodily injury," "property damage' or "personal and advertising injury" arising out of the rendering or failure to render any professional services by or for you, including but not limited to: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifications; and (2) Supervisors, inspection, or engineering services. Any coverage provided under this provision shall be excess over any other valid and collectible insurance available to the Additional Insured(s) whether primary, excess, contingent or on any other basis unless a contract specifically requires that this insurance be primary or you request that it apply on a primary basis. Paragraph 3a. of Section II — Who Is An Insured is deleted and replaced by the following: a. Coverage under this provision is, subject to (1) and (2) below: (1) Effective on the acquisition or formation date; and (2) Afforded only until the end of the policy period. E) KNOWLEDGE OR NOTICE OF OCCURRENCE 1) As respects any loss reporting requirements under this policy, it is understood and agreed that knowledge of an "occurrence" by an agent, servant or employee of yours or any other person shall not in itself constitute knowledge by you, unless a corporate officer of yours shall have received notice from said agent, servant, employee or any other person. 00 GL0295 00 02 09 Page 3 of 7en-,t 0 2) Your failure to give first report of an "occurrence" to us shall not invalidate coverage under this policy if the loss was inadvertently reported to another insurer. However, you shall report any such "occurrence" to us within a reasonable time once you become aware of such error. F) ADVERTISING INJURY—TELEVISED, VIDEOTAPED, OR INTERNET -BASED PUBLICATION 1) The definition of "Personal and Advertising Injury' item 14. is changed to read: "Personal and Advertising Injury" means injury arising out of one or more of the following offenses: d) Oral, written, televised, videotaped, or internet-based publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products, or services: e) Oral, written, televised, videotaped, or internet-based publication of material that violates a person's right of privacy; f) Misappropriation of advertising ideas or style of doing business; or g) Infringement of copyright, title, or slogan. 2) Exclusions band c. of Coverage B., Personal and Advertising Injury Liability, are changed to read: a) (2) Arising out of oral, written, televised, videotaped, or internet-based publication of material, if done by or at the direction of the insured with knowledge of its falsity; b) (3) Arising out of oral, written, televised, videotaped, or internet-based publication of material whose first publication took place before the beginning of the policy period. G) BODILY INJURY— MENTAL ANGUISH The definition of "bodily injury" is changed to read: "Bodily Injury": a) Bodily injury, sickness, or disease sustained by a person, and includes mental anguish resulting from any of these; and b) Except for mental anguish,' includes death resulting from the foregoing (item a. above) at any time. H) UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. LIBERALIZATION If we adopt a change in our forms or rules which would broaden your coverage without an additional premium charge, your policy will automatically provide the additional coverage(s) as of the date the revision is effective in your state. J) EXTENDED "PROPERTY DAMAGE" SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions a. is deleted and replaced by the following: 1) Expected or Intended Injury; "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage' resulting from the use of reasonable force to protect persons or property. K) PREMISES SOLD OR ABANDONED BY YOU SECTION I -COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, Exclusion j. is amended as follows: Paragraph (2) is replaced by the following: (2) Premises you sell, give away, or abandon, if the "property damage" arises out of any part of �y those premises and occurred from hazards that were known by you or should have reasonably been known by you, at the time the property was transferred or abandoned. 00 GL0295 00 02 09 Page 4 ofr7 rr o� ADDITIONAL INSURED — FUNDING SOURCE Under SECTION II — WHO IS AN INSURED the following is added: OL) : 2) Any person or organization with respect to their liability arising out of: a) Their financial control of you; or b) Premises they own, maintain, or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction, and demolition operations performed by or for that person or organization. M) ADDITIONAL INSURED — MANAGERS OR LESSORS OF PREMISES Under SECTION II —WHO IS AN INSURED the following is added: 1.f. Any person or organization with respect to their liability arising out of the ownership, maintenance, or use of that part of the premises leased to you, subject to the following additional exclusions: This insurance does not apply to: a) Any "occurrence" which takes place after you cease to be a tenant in that premises. b) Structural alteration, new construction, or demolition operations performed by or on behalf of that person or organization. N) ADDITIONAL'INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT 1) Any person or organization is an insured with whom you are required to add as an additional insured to this policy by a written contract or written agreement, or permit that is: a) currently in effect or becoming effective during the term of this policy; and b) executed prior to the "bodily injury," "property damage," "personal and advertising injury". 2) This insurance provided to the additional insured by this endorsement applies as follows: a) That person or organization is only an additional insured with respect to liability caused by your negligent acts or omissions at or from: (1) Premises you own, rent, lease, or occupy, or (2) Your ongoing operations performed for the additional insured at the job indicated by written contract or written agreement. b) The limits of insurance applicable to the additional insured are those specified in the written contract or written agreement or in the Declarations of this policy whichever is less. These limits of insurance are inclusive of and not in addition to the limits of insurance shown in the Declarations. 3) With respect to the insurance afforded these additional insured's, the following additional exclusions apply: a) This insurance does not apply to "Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment.furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations on or at the same project. b) This insurance does not apply to "bodily injury," "property damage," "personal and advertising injury" caused by the rendering of or failure to render any professional services. 4) Regardless of whether other insurance is available to an additional insured on a primary basis, this insurance will be primary and noncontributory if a written contract between you and the additional insured specifically requires that this insurance be primary. 00 GL0295 00 02 09 Page 5 of 7 ��is O) GENERAL AGGREGATE LIMIT PER LOCATION SECTION III — LIMITS OF INSURANCE, is amended as follows: 2. The General Aggregate Limit is the most we will pay for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage' included in the "products -completed operations hazard, and C. Damages under Coverage B. A separate Location General Aggregate Limit applies to each 'location' and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. SECTION V - DEFINITIONS is amended by adding the following: 23. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. P) BLANKET SPECIAL EVENTS AND FUND RAISING EVENTS 1) This insurance applies to your legal liability for "bodily injury," "property damage," and "personal and advertising injury" arising out of all your managed, operated or sponsored special events WITH THE FOLLOWING EXCEPTIONS: a) Events involving aircraft b) Events involving automobile or motorcycle races or rallies C) Events involving fireworks d) Events involving firearms e) Events involving live animals, excluding domestic pets f) Carnivals and fairs with mechanical rides g) Any event lasting more than three (3) days (including otherwise acceptable events) h) Any event with greater than 1,000 people in attendance (including otherwise acceptable events) Coverage may be provided by endorsement issued by us.and made part of this Coverage Part, and subject to an additional premium charge. Q) NON -OWNED WATERCRAFT SECTION I —COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, paragraph g.(2) is amended to read as follows: (2) A watercraft you do not own that is: a) Less than 65 feet long, and b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess, or contingent. R) WAIVER OF SUBROGATION We will waive our right of subrogation in the event of a loss. We must be advised in writing, prior to the loss, of your intention to waive subrogation. We also must know whom subrogation will be waived against. If your request meets our underwriting criteria regarding such waivers, we will waive our right. However, we reserve the right to charge additional premium or to limit the terms and conditions of such waiver. S) WAIVER OF IMMUNITY We will waive, both in the adjustment of claims and in defense of "suits" against the insured, any charitable or governmental immunity of the insured, unless the insured requests, in writing, that we not do so. Waiver of immunity, as a defense, will not subject us to liability for any portion of a claim or judgment, in excess, of the applicable limit of insurance. T) VIOLATION OF RIGHTS OF RESIDENTS (PATIENT'S RIGHTS) 00 GL0295 00 02 09 Page 6 of 7 1) The followingtadded to SECTION 1 — COVERAGES CO4ERAGE A BODILY INJURY AND PROPERTY DAMAGE — paragraph 1. Insuring Agreement: "Bodily Injury" damages arising out of the violation of "Rights of Residents," shall be deemed an "occurrence." 2) As respects the coverage provided in paragraph A.I. of this endorsement, the following exclusions are added to SECTION I — COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE — 2. Exclusions: This insurance does not apply to: a) Liability arising out of the willful or intentional violation of "Rights of Residents." b) Fines or penalties assessed by a court or regulatory authority. C) Liability arising out of any act or omission in the furnishing, or failure to furnish, professional services in the medical treatment of residents. 3) As respects the violation of "Rights of Residents" Coverage, the following definition is added to SECTION V - DEFINITIONS: 24. "Rights of Residents" means: a. Any right granted to a resident under any state law regulating your business as a health care facility. b. The "Rights of Residents' as included in the United States Department of Health and Welfare regulations governing participation of Intermediate Care Facilities and Skilled Nursing Facilities, regardless of whether your facility is ' subject to those regulations. U. LIQUOR LIABILITY EXCLUSION — EXCEPTION FOR SPECIAL EVENTS OR FUNDRAISING EVENTS SECTION 1. COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions c. is amended by adding the following subparagraph: This exclusion does not apply to "bodily injury" or "property damage" arising out of the selling, serving or furnishing of alcoholic beverages at any special events or fundraising events related to the insured's business. V. EMPLOYEE CRIMINAL DEFENSE COVERAGE Under SUPPLEMENTARY PAYMENTS — COVERAGES A AND B, the following is added: 3. We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding. The alleged criminal act must arise out of the "employee's" work performed on your behalf. The most we will pay for any "employee" who is alleged to be directly proceeding is $25,000 regardless of the number of "employees', claims persons or organizations making claims or bringing "suits". All other terms and conditions of this Policy remain unchanged. Endorsement Number: Policy Number: Named Insured: involved in a criminal or "suits" brought or This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 00 GL0295 00 02 09 Page 7 of 7 ,� 00� ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ODIYYYY) 08/01/2018 THIS CERTIFICATE IS ISSUED ASA 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(les) must have ADDITIONAL INSURED provisions or 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 CONTACT Nilda Garcia .- NAME: Hays Companies PAHONNOEan, (909)243-8111 / AIC, No: 4200 Concours, Suite #350 E-MAIL ngarcia@hayswmpanies.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC9 INSURERA: Arch Insurance Company 11150 Ontario CA 91764 INSURED INSURER B: Cypress Insurance Company 10855 Boys & Girls Clubs of Central Orange Coast '� INSURER C: 17701 Cowan, Suite 110 INSURER D: INSURER E: Irvine CA 92614 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1852360822 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADULSUBR INSD MO POLICYNUMBER POLICYEFF MMIDD/YYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GIAIMS-MADE 71 OCCUR PREMISES Ea commence $ 1.000,000 Professional Liabilty, MED EXP (Any oneperson) $ 20,000 XSexual Misconduct 1.000,000 A Y AAPKGO028800 02/11/2018 02/11/2019 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 3,000,000 POLICY E JECT PRO- F-13,000,000 LOC PRODUCTS-COMP/OP AGG $ SEXUALABUSECOV s 1,000,000 OTHER: AUTOMOBILE LIABILITY COMINEDSINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Par person) $ ANYAUM A OWNED SCHEDULED AUTOS ONLY AUTOS AAAUT0028800 02/11/2018 02/11/201 BODILY I NJURY(Per accident) $ HIRED NONAWNEO q PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident I Medical payments $ 5,000,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS -MADE AAFXS0028800 02/11/2018 02/11/201 Or AGGREGATE $ DED I X RETENTION $ 10,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITYY STATUTE ER E.EACH ACCIDENT $ 1.000,000 L. B ANY ECUTIVE ❑ eR NIA BOWC914957 06/01/2018 06/01/20 19 OFFCEMMEM ExcO ED (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Property RIC: Spcl Form A AAPKGO028800 02/11/2018 02/11/2019 Blanket BPP: $1,011,000 Deductible: $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe adached if more space Is required) The City of Santa Ana is Additional Insured; CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SOCIAL SERVICES PREMIER GENERAL LIABILITY ENHANCEMENT ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposures are provided under this policy. If such specific coverage applies, the terms, conditions, and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your" refer to the "Named Insured" shown in the Declarations. The words "we", "us", and "our" refer to the "Company" providing this insurance. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is a summary of the Limits of Insurance and Additional Coverage provided by this endorsement. For complete details on specific coverage's, consult the policy contract wording. A) Medical Payment — Limit increased to $20,000 B) Supplementary Payments — Bail bonds increased to $3,000 / Loss of Earnings increased to $1,000 each day C) Damage to Premises Rented to You — Fire, Lightning, Explosion, Smoke and Leaks from Fire Protective Sprinklers limit increased to $1,000,000 D) Broadened definition of Who is an Insured E) Knowledge or Notice of Occurrence F) Broadened definition of Advertising Injury includes televised, videotaped, or internet-based publication G) Amended definition of Bodily Injury to include mental anguish H) Amended Unintentional Failure to Disclose Hazards 1) Amended Liberalization Clause J) Property Damage — Removal of exclusion for "Property Damage" resulting from the use of reasonable force to protect persons or property K) Premises Sold or Abandoned by You L) Added Blanket Additional Insured - Funding sources M) Added Blanket Additional Insured - Managers or lessors of premises N) Additional Insured — By Contract, Agreement or Permit O) General Aggregate Limit Per Location P) Blanket Special Events and Fund Raising Events Coverage Q) Non -Owned Watercraft Coverage - Length is increased to 65 feet R) Blanket Waiver of Subrogation S) Waiver of Immunity T) Violation of Rights of Residents Coverage (Patient's Rights) U) Liquor Liability Exception to Exclusion V) Employee Criminal Defense Coverage - $25,000 limit A) MEDICAL PAYMENTS If Medical Payments Coverage (Coverage C) is not otherwise excluded from this Coverage Part: 1) The Medical Expense Limit is increased, subject to all the terms of Limits of Insurance (Section III) to $20,000 2) The requirement in the Insuring Agreement of Coverage C, that expenses must be incurred and reported to us within "one year" of the accident date is changed to "three years." B) SUPPLEMENTARY PAYMENTS Coverage A. and B. provisions: 1) The limit for the cost of bail bonds is changed from $250 to $3,000. 2) The limit for loss of earnings is changed from $250 per day to $1,000 per day. f]� 00 GL0295 00 02 09 Page 1 of 7 C) DAMAGE TO PREMISES RENTED TO YOU If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" and the words "fire insurance' are changed to "fire, lightning, explosion, smoke, or leakage from fire protective sprinklers" where it appears in: 1) The last paragraph of Section I — Coverages, Coverage A Bodily Injury And Property Damage Liability, subsection 2. Exclusions; 2) Section III — Limits Of Insurance, paragraph 6.; 3) Section V — Definitions, paragraph 9.a. 4) Section IV— Commercial General Liability Conditions, subsection 4. Other Insurance, paragraph b. Excess Insurance The Damage to Premises Rented to You Limit section of the Declarations is amended to $1,000,000. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke or leakage from fire protective sprinklers or any combination thereof. D) WHO IS AN INSURED Paragraph 2. of Section II — Who Is An Insured is deleted and replaced by the following: 2. Each of the following is also an insured: but only while working within the scope of their duties for the insured: a. (i) "Employees"; (ii) "Volunteer Workers"; (iii) Independent Contractors However, no "employees", "volunteer workers" or independent contractors are insureds for: (1) 'Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are al limited liability company), to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (2) "Property damage' to property: (a) Owned, occupied or used by, (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). b. Medical directors and administrators, including professional persons, are also insureds; c. If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds; d. If you are a limited liability company your members are insureds, but only with respect to their duties related to the conduct of your business; e. Any organization and subsidiary thereof which you control and actively manage on the effective date of this endorsement; n„ . , t�J �` AKN 6A—i% 00 GL0295 00 02 09 Page 2 of 7 f. Any person or organization that has financial control of you or owns, maintains or controls premises occupied by you and requires you to name them as an additional insured but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. g. Any state or political subdivision subject to the following provision: This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: (1) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar exposures; or (2) The construction, erection, or removal of elevators; or (3) The ownership, maintenance, or use of any elevators covered by this insurance. However, the insurance afforded for any organization and subsidiary thereof not named in the Declarations as a Named Insured, does not apply to injury or damage with respect to which an insured under this endorsement is also an insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. h. Students in training, but not for "bodily injury' or "property damage" arising out of his or her rendering or failure to render professional services to patients; i. Your members but only with respect to their liability for your activities or activities they perform on your behalf; j. Your trustees or members of the board of governors while acting within the scope of their duties as such on your behalf; k. Any entity you are required in a written contract (hereinafter called Additional Insured) to name as an insured is an insured but only with respect to liability arising out of your premises, "your work" for the Additional Insured, or acts or omissions of the Additional Insured in connection with the general supervision of "your work" to the extent set forth below: Insurance does not apply to "bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering or failure to render any professional services by or for you, including but not limited to: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifications; and (2) Supervisors, inspection, or engineering services. Any coverage provided under this provision shall be excess over any other valid and collectible insurance available to the Additional Insured(s) whether primary, excess, contingent or on any other basis unless a contract specifically requires that this insurance be primary or you request that it apply on a primary basis. Paragraph 3a. of Section II — Who Is An Insured is deleted and replaced by the following: a. Coverage under this provision is, subject to (1) and (2) below: (1) Effective on the acquisition or formation date; and (2) Afforded only until the end of the policy period. E) KNOWLEDGE OR NOTICE OF OCCURRENCE 1) As respects any loss reporting requirements under this policy, it is understood and agreed that knowledge of an "occurrence" by an agent, servant or employee of yours or any other person shall not in itself constitute knowledge by you, unless a corporate officer of yours shall have received notice from said agent, servant, employee or any other person. Qs -,,U, -tg 00 GL0295 00 02 09 Page 3 of 7 2) Your failure to give first report of an "occurrence" to us shall not invalidate coverage under this policy if the loss was inadvertently reported to another insurer. However, you shall report any such "occurrence" to us within a reasonable time once you become aware of such error. F) ADVERTISING INJURY—TELEVISED, VIDEOTAPED, OR INTERNET -BASED PUBLICATION 1) The definition of "Personal and Advertising Injury" item 14. is changed to read: "Personal and Advertising Injury" means injury arising out of one or more of the following offenses: d) Oral, written, televised, videotaped, or internet-based publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products, or services; e) Oral, written, televised, videotaped, or internet-based publication of material that violates a person's right of privacy; f) Misappropriation of advertising ideas or style of doing business; or g) Infringement of copyright, title, or slogan. 2) Exclusions b.and c. of Coverage B., Personal and Advertising Injury Liability, are changed to read: a) (2) Arising out of oral, written, televised, videotaped, or internet-based publication of material, if done by or at the direction of the insured with knowledge of its falsity; b) (3) Arising out of oral, written, televised, videotaped, or internet-based publication of material whose first publication took place before the beginning of the policy period. G) BODILY INJURY—MENTAL ANGUISH The definition of "bodily injury" is changed to read: "Bodily Injury": a) Bodily injury, sickness, or disease sustained by a person, and includes mental anguish resulting from any of these; and b) Except for mental anguish, includes death resulting from the foregoing (item a. above) at any time. H) UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. LIBERALIZATION If we adopt a change in our forms or rules which would broaden your coverage without an additional premium charge, your policy will automatically provide the additional coverage(s) as of the date the revision is effective in your state. J) EXTENDED "PROPERTY DAMAGE" SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions a. is deleted and replaced by the following: 1) Expected or Intended Injury; "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. K) PREMISES SOLD OR ABANDONED BY YOU SECTION I -COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, Exclusion j. is amended as follows: Paragraph (2) is replaced by the following: (2) Premises you sell, give away, or abandon, if the "property damage" arises out of any part of those premises and occurred from hazards that were known by you or should have reasonably been known by you, at the time the property was transferred or abandoned. 00 GL0295 00 02 09 Page 4 of 7 L) ADDITIONAL INSURED — FUNDING SOURCE Under SECTION II — WHO IS AN INSURED the following is added: 2) Any person or organization with respect to their liability arising out of: a) Their financial control of you; or b) Premises they own, maintain, or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction, and demolition operations performed by or for that person or organization. M) ADDITIONAL INSURED— MANAGERS OR LESSORS OF PREMISES Under SECTION II — WHO IS AN INSURED the following is added: 1.f. Any person or organization with respect to their liability arising out of the ownership, maintenance, or use of that part of the premises leased to you, subject to the following additional exclusions: This insurance does not apply to: a) Any "occurrence" which takes place after you cease to be a tenant in that premises. b) Structural alteration, new constructio or demolition operations performed by or on behalf of th erson o anization. N) ADDITIONAL INSUREDS - BY CONTRAC AGREEMENT OR PERMIT 1) Any person or organization is an i red with who ou are required to add as an additional insured to this policy by a w 'ttea cant act or written agreement, or permit that is: a) currently in effect or becoming effective during the term of this policy; and b) executed prior to the "bodily injury," "property damage," "personal and advertising injury". 2) This insurance provided to the additional insured by this endorsement applies as follows: a) That person or organization is only an additional insured with respect to liability caused by your negligent acts or omissions at or from: (1) Premises you own, rent, lease, or occupy, or (2) Your ongoing operations performed for the additional insured at the job indicated by written contract or written agreement. b) The limits of insurance applicable to the additional insured are those specified in the written contract or written agreement or in the Declarations of this policy whichever is less. These limits of insurance are inclusive of and not in addition to the limits of insurance shown in the Declarations. 3) With respect to the insurance afforded these additional insured's, the following additional exclusions apply: a) This insurance does not apply to "Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations on or at the same project. b) This insurance does not apply to "bodily injury," "property damage," "personal and advertising injury" caused by the rendering of or failure to render any professional services. 4) Regardless of whether other insurance is available to an additional insured on a primary basis, this insurance will be primary and noncontributory if a written contract between you and the additional insured specifically requires that this insurance be primary. 00 GL0295 00 02 09 Page 5 of 7 O) GENERAL AGGREGATE LIMIT PER LOCATION SECTION III — LIMITS OF INSURANCE, is amended as follows: 2. The General Aggregate Limit is the most we will pay for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage' included in the "products -completed operations hazard, and C. Damages under Coverage B. A separate Location General Aggregate Limit applies to each "location" and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. SECTION V - DEFINITIONS is amended by adding the following: 23. "Location' means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. P) BLANKET SPECIAL EVENTS AND FUND RAISING EVENTS 1) This insurance applies to your legal liability for "bodily injury," "property damage," and "personal and advertising injury' arising out of all your managed, operated or sponsored special events WITH THE FOLLOWING EXCEPTIONS: a) Events involving aircraft b) Events involving automobile or motorcycle races or rallies C) Events involving fireworks d) Events involving firearms e) Events involving live animals, excluding domestic pets f) Carnivals and fairs with mechanical rides g) Any event lasting more than three (3) days (including otherwise acceptable events) h) Any event with greater than 1,000 people in attendance (including otherwise acceptable events) Coverage may be provided by endorsement issued by us and made part of this Coverage Part, and subject to an additional premium charge. Q) NON -OWNED WATERCRAFT SECTION I — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions, paragraph g.(2) is amended to read as follows: (2) A watercraft you do not own that is: a) Less than 65 feet long, and b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess, or contingent. R) WAIVER OF SUBROGATION We will waive our right of subrogation in the event of a loss. We must be advised in writing, prior to the loss, of your intention to waive subrogation. We also must know whom subrogation will be waived against. If your request meets our underwriting criteria regarding such waivers, we will waive our right. However, we reserve the right to charge additional premium or to limit the terms and conditions of such waiver. S) WAIVER OF IMMUNITY We will waive, both in the adjustment of claims and in defense of "suits" against the insured, any charitable or governmental immunity of the insured, unless the insured requests, in writing, that we not do so. Waiver of immunity, as a defense, will not subject us to liability for any portion of a claim or judgment, in excess, of the applicable limit of insurance. T) VIOLATION OF RIGHTS OF RESIDENTS (PATIENT'S RIGHTS), 8 (—tcU Ut 00 GL0295 00 02 09 Page 6 of 7 1) The following is added to SECTION 1 — COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE — paragraph 1. Insuring Agreement: "Bodily Injury" damages arising out of the violation of "Rights of Residents," shall be deemed an "occurrence." 2) As respects the coverage provided in paragraph A.1. of this endorsement, the following exclusions are added to SECTION I — COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE — 2. Exclusions: This insurance does not apply to: a) Liability arising out of the willful or intentional violation of "Rights of Residents." b) Fines or penalties assessed by a court or regulatory authority. C) Liability arising out of any act or omission in the furnishing, or failure to furnish, professional services in the medical treatment of residents. 3) As respects the violation of "Rights of Residents" Coverage, the following definition is added to SECTION V - DEFINITIONS: 24. "Rights of Residents" means: a. Any right granted to a resident under any state law regulating your business as a health care facility. b. The "Rights of Residents" as included in the United States Department of Health and Welfare regulations governing participation of Intermediate Care Facilities and Skilled Nursing Facilities, regardless of whether your facility is subject to those regulations. U. LIQUOR LIABILITY EXCLUSION — EXCEPTION FOR SPECIAL EVENTS OR FUNDRAISING EVENTS SECTION 1. COVERAGES COVERAGE A BODILY INJURY AND PROPERTY DAMAGE 2. Exclusions c. is amended by adding the following subparagraph: This exclusion does not apply to "bodily injury" or "property damage" arising out of the selling, serving or furnishing of alcoholic beverages at any special events or fundraising events related to the insured's business. V. EMPLOYEE CRIMINAL DEFENSE COVERAGE Under SUPPLEMENTARY PAYMENTS — COVERAGES A AND B, the following is added: 3. We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding. The alleged criminal act must arise out of the "employee's" work performed on your behalf. The most we will pay for any "employee" who is alleged to be directly proceeding is $25,000 regardless of the number of "employees", claims persons or organizations making claims or bringing "suits". All other terms and conditions of this Policy remain unchanged. Endorsement Number: Policy Number: Named Insured: involved in a criminal or "suits" brought or This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 00 GL0295 00 02 09 Page 7 of 7 OF