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Home My WebLink AboutQUEENS PUBLIC LIBRARY (2)p City of Santa Ana f'19� Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. The agreement with No. was completed on (List all amendments. Use space below if needed.) A- a-t) 20V FEB -6 .PII IR CITY pF OTC Office Use Only CEf?N n r%,., ., and final payment has been made. Department: i4 j byQn•I�c Phone/Ext.:S� Signature:Q''�tt� Date: �7/� INSURANCE NOT ON FILE MAYOR WORK MAY Nfff�PROCEED uel A. Pulldo MAYOR PRO TEM CLERK OF COUNCi Michele Martinez COUNCILMEMSERS OC� 2017 P. David Benavides 4 Vicente Sarmiento Jose Solorio /may Sal Tlnatero JuanVlllegas CI'T'Y OF SANTA ANA OYP3 ` nA OFFICE OF THE CITY A77ORNEY St i VL. A- 20 Civic Center Plaza, M29 • P,O, Box 1988 Santa Ana, California 92702 714.647-5201 s Fax 714-647.6515 www santa-ane ora August 31, 2017 Queens Borough Public Library. Attn: President and CEO 89-11 Merrick Blvd. Jamaica, NY 11432 Re: "Consultant Agreement" Extension Dear Mr. Walcott: A-2015-006-01 INTERIM CITY MANAGER Cynthia J. Kurtz CITY ATTORNEY Soria R- Carvalho CLERK OF THE COUNCIL Marie D. Huizar In accordance with the terms and conditions of the 2014 Federal Institute of Museum and Library Services (ITYILS) National Leadership Grant Program, the City of Santa Ana received approval for a no -cost extension from the IMLS to extend the award dates for the Grant. Pursuant to Section 3 ("Term") of Agreement No. A-2015-006 entered into by Queens Borough Public Library and the City of Santa Ana, dated December 1, 2014, the time period of said Agreement is hereby extended for an additional one (1) year period from October 1, 2017 to September 30, 2018, The insurance certificates are required to be extended and/or renewed to cover this extension. All other terns and conditions of said Agreement remain unchanged and in full force and effect, Please review, sign, and return this extension letter indicating your agreement, f I If you have any questions regarding'this matter, please contact Francisco Arroyo in the Parks, Recreation and Community Services Agency at 714-571-4218. Sincerely, Y OF S TA ANA Cynthia J. urtz Interiat City Manager [Signatures continued on next page] ATTEST: a L�Marg D. Huizaruizar Clerk of the Council SANTA ANA CITY COUNCIL Mguei A. Pulido Michele Martinez vice,te Sarmiento Jose Sotorlo P, OeWd Benevides Juan vilm9as Sal Tmaloro Mayor Mayor Pro Tem, Ward 2 Ward Ward Ward Ward Ward mn Ild,(1q t Aaawrg mlrnanlneznaanw—ana.orn y,awnientoransania-ena.arn solo', Arta:gne,ara d a avidesGdsama-A0@nJg Iv'lleoasAsente-ene.ora slinatero(dseMa-eaa.ora Signature page — Extension Letter with Queens Borough Public Library APPROVED AS TO FORM: RECOMMENDED FOR APPROVAL: Sonia R. Carvalho City Attomey �J ' �h Co �l h0. l" 9yYu 1 n Laura A. Rossini Gerardo A. Mouet Senior Assistant City Attorney Executive Director, Parks, Recreation and Community Services Agency CONSULTANT QUEENS BOROUGH PUBLIC LIBRARY Dennis M. Walcott President and CEO c: Clerk of the Council SANTA ANA CITY COUNCIL Mguel A. Pulldo Michele Monlnez Vicente sanelemo Jose Boland P. WOW Benaddes Juan Villegan Sal 71M Maya Mayor No Tent Ward 2 Ward t Wow s Ward a Ware s Word mnu5do@aanla�enagp mlmawnez�sanlwene.am year n'onlofdsantea dem jaolorW�y�le-ane ara nbanaoitlesRasanla•nna.orn ry91pgg5�aenlaenn nrn 511 ielemWavai Ik CERTIFICATE OF LIABILITY INSURANCE ( DATE,MMI°°fYYYY7 cta Iona l 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 poiicy{ies) must have ADDITIONAL INSURED provisions 01, be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement, A statement on this cortiHcato does not confer rights to the certificate holder in lieu of such endorsement(s).- PRODUCER CONTACT Arthur J. Gallagher Risk Management Services, Inc. PHONE (510 745-0800 FAX A ° H ) Nel:{516) 745-0082 One Jericho Plaza Suite 200 .Exp: (AIG Jericho, NY 11758- L aooR ADDR Ess: INSURERS) AFFORDING COVERAGE NAZCA j INSURER A: Federal Insurance Company :20281 INSURED INSURER a Great Northern Insurance Company 1..20303 1 I Queens Borough Public Library INSURER e: 89-11 Merrick Blvd. INSURER D: !, Jamaica, NY 11432 INSURER E INSURER F:___....-..... COVERAGESCERTIFICATE NUMBER: REVISION NUMBER___ THIS IS 10 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 FFSPEC.I TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PER"rAIN, THE INSURANCE AFFORDED BY THE POL.ICIFS DESCRIBED HEREIN IS SUBJECTTO ALL. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ I INS" 'ADDL'SUOR L LIE, TYPE VF INSURANCE TURG, W};p POLICY NUMBER1nfLv1fOPIYYYY) POLICY EFF POLICY EXP iMMePS1fYYYY',-___, LIMITS "__ p A : X COMMERCIAL GENERAL LIABILITY _ — EACH OCCURRENCE $ 1'000'000} i CLAIMS MADE X ` OCCUR :OL--- 9949 69 92 06791(2017 0610112018 DAMAGE 10 RENTED � 1,000,000 PREMISES {EA occurrencsi j 10*0001 MED EXP G,ny ole person) IX 1,000,0001 „PERSONAL&AEG INJURY $ 1 GEN L AEGA EGA I' G LIMIT APPLIES PER GENERAL AGGREGA IC i 21000,0001 1, POLICY IIRCQr X LOC '., PRODUCTS -COM PIOP ACU ` Included!! OTI IER B" AUTOMOBILE LIABILITY COMBINED COMBINED SINGLE LIMIT "-1,000,000 auc tle n( ''., 5 X ANY AU 10 73598196 0610112017,,06/01/2018 BODILY INJURY (Per peso) $ OWNH'J SCHEDULED AUTOS ONLY - AUTOS BODILY INJURY (Per .,,NLni) $ DAMAGE ROUIaONLY NON-0�NED (PROPERitlY r, UMBRELLA LiAB OCCUR EACH OCCURRENCE S EXCESS LAS CLAWS -MADE AGGREGATESPER HL (ENTION $. COMPENSATION COM TniUTE ORi AND EMRS AND EMi>LOYERS i-IABWry YtN ' WORKERS GR/PART NERIEXECU LIVE EL EAU I AOCIDEN'1 $ OEFICENMEMpp{V�-�g,EXCLUDED" NIA [ (Mandarory h', NH( E. L. DISEASE LA EMPLOYEE$ If yeS debcl'hb0 natter DESCRIPTION OP OPERAPOPIS below EL DISEASE POLICYLIMIT '. $ i I 6y�o x-� _ _O_F R I LOCATIONS I VEHICLES (05-07 101, Additional rtemarQs Schedule, may ba atlached If mo,e apac® Is repmred) ADDI HONAL INSUREDPER FORM 1105-07+..•' kThe City of Santa Ana, its officers, employees, agents, and representative are included as Additional insureds CERTIFICATE HOLDER CANCELLATION City of Santa Ana Attn: PRCSA 20 Civic.. Center Plaza -Ross Annex Santa Ana, CA 92701 SHOULD ANY OF THE. ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ��&O ACORD 25 (2016103) Oc 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF -INSURER STATE NATIONAL INSURANCE COMPANY, INC. Name of Excess Insurance Carrier C/O US SPECIALTY UNDERWRITERS 6140 PARKLAND BLVD, SUITE 300, MAYFIELD HEIGHTS. OH 44124 Address, City, State, Zip THIS IS TO CERTIFY that a Workers' Compensation Excess Insurance Contract has been issued by this Company as follows: The Excess Insurance Contract is now in force and the Company will give the Chair, Workers' Compensation Board, Attention: Office of Self -Insurance, 328 State Street, 3" Floor, Schenectady, NY 12305 not less than thirty (30) days written notice of cancellation or of any change to be made by the Company in said Contract. Such notice shall be sent by registered or certified mail or delivered by personal service as required in the Contract. Name Self -Insurer Queens Borough Public Library Address 89-11 Merrick Blvd., Jamaica, NY 11432 Contract Number NDE -0864177-16 Contract Effective 07/01/2016 until canceled. Company's Limits of Liability Statutory _ each occurrence. Self -Insurer's Retention $500,000 each occurrence. Dated this 21st day of June 20 16 STATE NATIONAL INSURANCE COMPANY INC. Name of Excess Insurance Company Authorized Representative' DEAN M. WILLIAMS, PRESIDENT Print Name of Representative 440-605-6100 Phone Number including Area Code " Attach evidence of authority e6 SI -21 (04-05) �e�oQi� G �19 a G�e�C�lCA° ADDITIONAL INSURED ENDORSEMENT Insurance Company Federal Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy #80-02-2357(5-07) relating to the following: The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; It officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, Is required to make this endorsement effective.) Effective 6/01/2017 Policy # 9049-69-92 1_10 Issued to Queens Borough Public Library this endorsement form as part of Name Insured Countersigned bvzl- Ireimance Agent Signature eda111` � �a5 G ®w«w& Compensation Board ANDREW M. CUOMO A zm:Mum », MCI oma J + Sums! KmqTfrcQ c» Wnkal cmp mPa Da /V--Zo| oo L --o1 LAnW wK See e Q the h0kn<G9eaG Board.D% m:r! 4cub.at: Name: cva &:.. G«;1i weew ± ;7431s: a.mm mem « Qualm» «I luis scafredco <manm its employces»«vG o G G S k mm. I _t» SCCti0II w Mlbdivisioll.Iz m *kms Compensation Ew. wma & + k ». en uwa ma above and remains in W Rime. Talus Co <. J y >snv>;smd46 ne< ,v 9 «e:uuca m »r,x,. < cave 9 m3nmL »«%w <m w<> mI VIA 1M, GNP� "o,� « «w=a <,« .. ...�: s:4 2n 24:nil, Vsm CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF -INSURER STATE NATIONAL INSURANCE COMPANY INC Name of Excess Insurance Cam or C/O US SPECIALTY UNDERWRITERS THIS IS TO CERTIFY that a Workers' Compensation Excess Insurance Contract has been issued by this Company as follows: The Excess Insurance Contract is now in force and the Company will give the Chair, Workers' Compensation Board, Attention: Office of Self-insurance, 328 State Street, 3" Floor, Schenectady, NY 12305 not less than thirty (30) days written notice of cancellation or of any change to be made by the Company In said Contract. Such notice shall be sent by registered or certified mail or delivered by personal service as required in the Contract. Name Self -Insurer Queens Borough Public Library Address 89-11 Merrick Blvd., Jamaica, NY 11432 Contract Number NDE -0927470.17 Contract Effective 07/01/2017 Company's Limits of Liability Statutory Sei6lnsurees Retention $600,000 Dated this 201h day of until canceled. each occurrence. Z6 \6A1 !aG°�V-dC�`!� 0\ 6 J ' Atlech evidence of aulhonty ^ , 19P SI -21 (04-05) �x each occurrence. June 20 17 STATE NATIONAL INSURANCE COMPANY. INC Name of Excess Insurance Company Authodzad Representative' DEAN M. WILLIAMS PRESIDENT Print Name of Ropresentatve 440-505.6100 Phone Number Including Area Code