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HomeMy WebLinkAboutVIDEO ENGINEERING SERVICES (THOMAS BYSTRY)City of Santa ." na Clerk of the Cou..cil AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. 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 ar m `.••"" A-2015-096-01 No. _ was completed on (List all amendments. Use space below if needed.) Revised: 16-18-16 r ���i il�Ili • • COTC Office Use Only City of Santa Ana 0 2 2021 Clerk of the Council has been made. Department: �K L�Ttl 1Nl i� L,r Phone/Ext.: Signature:x Date: N A-2015-096-01 MAYOR Miguel A. Pulido MAYOR PRO TEM Michele Martinez COUNCILMEMBERS P. David Benavldes Vicente Sarmlento Jose Solodo Sal Tinajero Juan \Alleges April 13, 2018 Mr. Thomas Eystry Video Engineering Services 16575 Donwest Tustin, California 92780 CITY OF SANTA ANA PARKS, RECREATION AND COMMUNITY SERVICES AGENCY 20 Civic Center Plaza M-23 • P.O. Box 1988 Santa Ana, California 02702 ys_w Santa-ana oro CITY MANAGER Raul Godinez II CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Hulzar Rc: Extension of Contractor Agreement No. A-2015-096 to provide video production services. Dear Mr. Eystry: Pursuant to Section 3 ("Term") of Agreement No. A-2015.096 entered into by you doing business as Video Engineering Services and the City of Santa Ana, dated June 2, 2015, the time period for said Agreement is hereby extended for an additional one (1) year period, from July 1, 2018 to June 30, 2019. The insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. Sincerely, Gerardo Monet Executive Director ' Parks, Recreation and Community Services Agency APPROVED AS TO FORM: Sonia R. Carvalho C Attorney Laura A. Rossini Senior Assistant City Attorney CITY OF SANTA- Raul Godinez II City Manager ATTEST: i Dqb M I Clerk of the I Council py SANTA ANA CITY COUNCIL Miguel A. Pulido Michele Martinez Vicente sanatoria Jose Solana _ RDavid aenavides Juan Villages Sal nnaiem Mayor Mayor No Tern, Ward 2 Ward Word Ward4 Wards Want Q�yJjdo'nzsaNa-ana ore t' a hR la a vsarrmentoAdflxntaana.ara Isotwla@sante-ana wa dbenevitlost@sa�rta-ana.oro iuiite¢as&eganiaana.om s6mtoro�sazr.e-a(ia.ara Alhw� DCERTIFICATE OF LIABILITY INSURANCE I DAozro22018rn 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT., If the certificate holder is an ADDITIONAL INSURED, the pall ey(les) must he endarsed, If SUBROGATION IS WAIVED, suh)oct to the terms and conditions of the policy, certain policies may require an endarsernent, A statement on this cortlRcate does not confer rights to the certificate holder In lieu of such endorsormards). PRODUCER CONTACI NAME: COASTAL BROKERS INSURANCE f FOR QUESTIONS CONTACT: PHONE TRITON OF CALIFORNIA INSURANCE SERVICES INC 2332AUBURN BLVD. INeURER(s)AFFORDINo COVERAOE� SACRAMENTO CA 95821 .,_..,„„•„,„,,,„,_v,,..,.�..„.,._.....,„„.„m...�„-„,.MESA UNDERWRITERS.kfNOIALTY INS C0 €NOR TOM 6YSTRY 1� _ "C "I�F` It+su qar .. ___.�_...v_. .a -.-... __. ....,.- ._ DBA: VIDEO ENGINEERING SERVICES LMQRIFR0'-----»—�� �----- -�M^ 18875DONWEST TUSTIN CA 92780 INURERE; o CVlornhl LNIu11CD. THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 ANQ OONOITIONS OF SUCH POLICIES, LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. IFFSR1— tYPE 4P INSURRNC6 lil POLICY NUMBER MMEO�EOPLY�b LIMITS GENERAL LIABILITY EN H OCCURPEJrE 1 1.000 000 'CACr1�'c -1 cOIatAERcwaaiHiveRSLLLd91LiTX � "C"r7C'li".-..- ;RT hI .�Ea�. urar a. Ib 1000 rLAIhI>,!,V k^OCCUR =MEC EK IAn4orle 4nraonl 165000 A MPo004009004649 Qz•01.18 02 Q119 pLNSDtaALa NiyIN IJa Is 10(10000 . 1F 0'{ AGBRF..+ATr 12,000,00 _ 6EJt hGOftE hTELNtIt APGi IES PPf;; I FROrji'T'-CIJPtaP'Sr 12000000 ¢FO- x AUTOMOBILE USAMWIW.�u 1 8 1 n:,141 CIL .- �1) 1 ALI- I ) 0000 HXR'Y )Par P9raxX'1t 1 vajE tAULEO - nu.n.•mIEL, ALTOS . Af1T05 I I �T 18 ! ) I ' HOCILv wd ar YIUKY 3 �� IP 11 Hipeo TDB AUTos 1 C eyak II It � UMBREIt.R LWe � Yr �4�' 1 9 � i �Gti�icvCCVRREbCB � S . e%CES4 LIAB rl JA' ACM1C*`_- ( �.a YIE+,ATC. } C RVrORKERS-COMPENSATIO $r B I t i lain- uft ANDWFLOVER'LIATWN ANYEMP6OYERS`41AaN.iT1' yI I ORYtIva IrORY 41MRd ANY F1`. G`nTNi IrNRTvER.,�;):-".,IJ�y>a CGbICC1ME.41EERE CI,I,L£Ci �;NFA � (Mandiea ANW 'T...<nm.. .. n tA9 455Li$3 ; ' Q�A1rztl ( ..i....n.. E LQI3..£ POLE Y LIMIT 13 I I I i I CGSCFOMRDFOPhRATIONSILOCA11ONSIWHICLES (AI%dh ACORF 101, Addieoebf ROM A$ Sarodu10,1more put is raggkad) ' %AL THE CITY OF SANTA APIA, ITS 6FFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES ARE NAMED ASADDI NINSURED FORM CG 2010ATTACHED TO THIS POLICY, THIS INSURANCE IS PRIMARY AND NON CONTRIBUTORY PER FORM Ct,; AT"f.�jCHEDT mS POLICY. CITY OF SANTA APIA FINANCE & MANAGEMENT SERVICESAGENCY P.O. BOX 1988 M-1 B SANTAANA CA 92702 SHOULD ANY OF THE THE EXPIRATION C ACCORDANCE WITH i I I 1 ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CANCELLED BEFORE Be DELIVERED IN POLICY NUMBER: MP0004009004049 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations Location(s) Of Covered Operations THE CITY OF SANTAANA ITS OFFICERS, VARIOUS EMPLOYEES, AGENTS AND REPRESENTATIVES % FINANCE & MANAGEMENT SERVICES AGENCY P.O. BOX 1988 M-16 SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A, Section II — Who Is An Insured is amended to Include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 2. 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 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. 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 location of the covered operations has been completed; or 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. �e o CG 20 10 0413 q0 Insurance Services Office, Inc., 2012 Page 1 of 2 POLICY NUMBER: MP0004009004049 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following Is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory 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. CG 20 01 0413 O Insurance Services Office, Inc., 2012 Page 1 of 1 GE I CO GEICO GENERAL INSURANCE COMPANY Washington DC VERIFICATION OF COVERAGE (SEE BELOW UNDER CAUTIONARY NOTE) MAILING ADDRESS Policy Number: 4353335278 THOMAS EUGENE, BYSTRY ,.. ,._ Effective Date: 12-05-17 16875 DONWEST Expiration Date: 06-05.18 TUSTIN.CA 82760-4052 _ .. _ Registered State: CALIFORNIA .. _.. __........... _.. ........... To whom it may concern: This letter is to verify that we have issued coverage under the above policy number for the dates indicated in the effective and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle meets or exceeds the financial responsibility requirement for your state. This verification of coverage does not amend, extend or alter the coverage afforded by this policy Vehicle Year: 2011 Make: HONDA Model: ELEMENT i VIN: 5J6YH1H32BL003266 COVERAGES LIMITS DEDUCTIBLES Bodily Injury Liability Each Person/Each Occurrence State Minimum $15,000/$30,0000 $100,000/$300,000 Property Damage Liability State Minimum $5,000 $50,000 Medical Payments $10,000 Uninsured & Underinsured Motorists Each Person/Each Occurrence $100,000/$300,000 Uninsured Motorists Property Damage $3,500 If you have any additional questions, please call 1-800-841-3000. CAUTIONARY NOTE: THE CURRENT COVERAGES, LIMITS, AND DEDUCTIBLES MAY DIFFER FROM THE COVERAGES, LIMITS AND DEDUCTIBLES IN EFFECT AT OTHER TIMES DURING THE POLICY PERIOD. THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES, LIMITS, AND DEDUCTIDLES AS OF THE ISSUED DATE OF THIS DOCUMENT WHICH IS SHOWN UNDER "ADDITIONAL INFORMATION" OR IF AN ISSUED DATE IS NOT SHOWN, THE DATE OF THIS FACSIMILE. U-33 10-07 ereby affirm Linder penalty of perjury, the following declaration ; I certify on behalf pf �L'� ' ' r �k�E (^ that during the term of my C'� aultan[(C mp( any Name) contract for���/ services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: L7 By: Name: �a Title: ((1� _ (/i j C (r p5jr erlti� e�Ne � 'e�b Telephone: �% I Gee��• WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. J� G National General A,t . Home & Health msu,aa,x PO Box 3199 - Winston Salem, NC 27102-3199 THOMAS E BYSTRY 16875 DONWEST TUSTIN CA 92780 Policy Number: 2006521219 Named Insured: Thomas E Bystry videotb@aol.com Policy Period: 1:32 PM 5/2112018 - 5121 /2019 Date of Notice: 6/21/2018 Policy Underwritten By: Integon National Insurance Company 24 Hour Claim Reporting: 1.8004683466 For Policy Information: 1.877468-3466 www.MyNatGenPolicy.com Your Agent: Fiesta Auto Insurance Center Store #CA078 1714 E McFadden Ave Suite P Santa Ana CA 92705 (714) 884-4284 CA COMMERCIAL VEHICLE DECLARATIONS PAGE Endorsement Effective 5/21/2018 The following changes were made to your policy - Driver Information Updated Drivers, Employees and Household Residents #1 Thomas E Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed Owner Driver XXX9358 CA 10/26/1967 Male Married 0 44 #2 Jennifer L Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pis Yrs. Licensed Relative CA 2/6/1978 Female Married 0 24 Excluded Insured Vehicle(s) and Schedule of Coverages #1 2011 HOND ELEMENT LX VIN: Usage: Personal Use Radius: 0 SJ6YH1H326L003266- Only BD3335 Garaging Location: 92780 Policy Coverage Level ScheduledAuto Coverages Provided Limits/DeductIbIas Premium Bodily Injury / Property Damage - Combined Single Limit $1,000,000 Combined Single Limit $910.00 Medical Payments $10.000 Each Person / Each Accident $65.00 Uninsured / Underinsured Motorist $100,000 Combined Single Limit $109.00 Combined Single Limit Total for this Vehicle $1 084.00 �1 e 10039CA(06012014`, p�G ACORl7® CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDONYTY) 02)07)2019 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy{ies) must have ADDITIONAL INSURED provieiens 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 Triton of Calif Insurance Services, Inc. CONTACT Chris Rudolph NAME: a°calf I (9is)985-1T05 uc Noi• (915N86-019B 2332 Auburn Blvd oREas: chris rtdtoninsumnce.com INSURER(SIAFFOP)INGCOVERAGE NAIC# Sacramento, CA 95821 _ License #: OF41767 INSURFRA: Mesa underwritersSpeciality Insurance Co. INSURED Ar 901J OR.��QI INSUMRO: INSURERC: TOM BYSTRY INEuaaaD: DBA: VIDEO ENGINEERING SERVICES NSURER B: 14 APPOMATTOX IRVINE, CA 92620 NEURER F: COVERAGES I'll Ir .Aam nj...c . wwww-.+.,... .._-._-_.__ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN_ MAY HAVE BEEN REDUCED BY PAID CLAIMS. -- - _ ADDL SUBN g1IDYEFF PoDCYEXP ILR TYPEOFINSURANCE I POLICY NUMBER A X OOMMERCIALGENERALLU&LnT Y Y MP0004009005022 071011201111'=01/2028 CI . ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS, LIMMS EACHOCCVRRENCE 3 1,000,000 GETO RFME➢ PREMIBE9 EaaEfl,R-- 3 1OO ODO MEDEXP anepxmn) $ 5000 CIAIMa�1MDE OCCUR PERSONALAADVINJURY s 1 000000 I i I OENERALAGGREGArm S 2,000,000 GENT AGGREMTE UMIT PPPUES PER: PRb Lrr- i X PCl1CV a .IECT PRODuOM-COMPIOP AM $ 1000000 3 O HER AUTOMOBILELLa&UTY LEU IT Ea 3 sol-Y INJURY (Pn prism) 3 ANVAUIO BOgLYINJURY(IW2Wdene 3 OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON-0WNEO i AUTOSONLY AUTOS ONLY PROPERTY OAMNGE nl 5 5 UMBREU-Aum OCCUR EACH OCCURRENCE 3 AGGREGATE 3 EXCESS LIAB CIAIMswA 3 OW RETENTION$ Y AXERSCOMPENSATIOM 8 LUTE OTK El -EACH ACCIDENT S ANDEMPLOYE1ar VAGUY y)N ANYPROPRIErOWPARTNEWEXECLrtrve ❑ OFFlCERAIEMBER EXCLUCEOT (MendatcrymNHJ NIA E.L DISEaeE- EA EMPLOY $ IIyes, tlesoibe order OESCRIPTONOF OPERATICNB below I I EL OMEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATMN81 LOCATIONS1 VEHICLES (AGORD101, Atltliepnal RemarNe Scbatluk, maY beaHvcMtl Mrepre span u nqulred) The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents and representatives are named as additional Insureds per CG2010 attached to this policy. The insurance is primary andennoncontribedry_`I s CITY OFSANTAANA SHOULDANYOFTHEABOVEOESC Pvitc TS)3�.C,f41CCLT-�EOBEFORE THE EXPIRATION OATE THERE TICEYA DIN FINANCE & MANAGEMENT SERVICES AGENCY ACCORDANCE WITH THE POLICY PROVISION PURCHASING DIVISION 20 CIVIC CENTER PLAZA M-16 AUTHORMEOaEP Santa Ana, CA 92702 An ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ed by CPR on February 07, 2019 at 02:58PM POLICY NUMBER: MP0004009005022 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) THE CITY OF SANTA ANA, IT'S OFFICERS, VARIOUS EMPLOYEES, AGENTS AND REPRESENTATIVES % FINANCE & MANAGEMENT SERVICES AGENCY P.O. BOX 1988 M-16 SANTAANA CA92702 Information required to complete this Schedule if not shown above will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to Include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, In whole or in part, by, 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: 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 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 20 10 04 13 0 Insurance Services Office. Inc., 2012 ��� Q Page 1 of 2 C. 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: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: MP0004009005022 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY — OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory 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. �y � Gue� 0,.�\� Sl,�pd CG 20 01 0413 0 Insurance Services Office, Inc., 2012 Page 11 of 1 WORKERS' COMPENSATION DECLARATION I / 0644E F 3T� hereby affirm under penalty of perjury, the (Name/Title) following declaration: �ihea S�,,dtces I certify on behalf of �A, rIPPI t & that during the term of my 4 %5.cs/ 26' p (Cons tant/Companyt me) contract for 7— / p ' za % 9 services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: j ) I By: 5 Name: V(Jv F,,',nw Servrces Title: o ('a Telephone: / ( 3 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Reviewed by: Silvia Cuevas PRCSAJAdmin. National General Auto. Mom! A HoAh Iniuran¢ PO Box 3199 • wlnston Salem. NC 27102-3199 THOMAS E BYSTRY 16875 DONWEST TUSTIN CA 92780 Policy Number: 2006521219 Named Insured: Thomas E Bystry videotb@aol.com Policy Period: 1:32 PM 5121/2018.6/21/2019 Date of Notice: 6/21/2018 Policy Underwritten By: Integon National Insurance Company 24 Hour Claim Reporting: 1-800r468.3466 For Policy Information: 1.877-468.3466 www.MyNatGenPolicy.com Your Agent: Fiesta Auto Insurance Center Store #CA078 1714 E McFadden Ave Suite P Santa Ana CA 92705 (714)884-4284 CA COMMERCIAL VEHICLE DECLARATIONS PAGE Endorsement Effective 612112018 The following changes were made to your policy - Driver Information Updated Drivers, Employees and Household Residents #1 Thomas E Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed Owner Driver XXX9358 CA 10/2611957 Male Married 0 44 #2 Jennifer L Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed Relative CA 2/6/1978 Female Married 0 24 Excluded Insured Vehicle(s) and Schedule of Coverages #1 2011 HOND ELEMENT LX VIN: Usage: Personal Use Radius: 0 5J6YH1H326L003266- Only BD3335 Garaging Location: 92780 Policy Coverage Level ScheduledAuto r'- Coverages Provided Limits/Deductibles Premium Bodily Injury I Property Damage - �$1,000,000 Combined Single Limit $910,00 Combined Single Limit Medical Payments $10,000 Each Person / Each Accident $65.00 Uninsured / Underinsured Motorist $100,000 Combined Single Limit $109.00 Combined Single Limit Total for this Vehicle $1 084.00 ed 10039CA(D6012014; c\\J C,\Ne o- ��C,