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22-001 Amendment #1 dated 6-27-24 Aboli Jaydeep for Fitness Instruction1 FIRST AMENDMENT TO AGREEMENT 22-001 BETWEEN THE CITY OF CUPERTINO AND ABOLI JAYDEEP RANADE FOR FITNESS INSTRUCTOR This First Amendment to Agreement 22-001 is by and between the City of Cupertino, a municipal corporation (hereinafter "City") and ABOLI JAYDEEP RANADE, a Sole Proprietorship/Individual (“Contractor”) whose address is 95014, and is made with reference to the following: RECITALS: A. On June 30, 2022, Agreement 22-001 (“Agreement”) was entered into by and between City and Contractor for Fitness Instructor. B. City and Contractor desire to modify the Agreement on the terms and conditions set forth herein. NOW, THEREFORE, it is mutually agreed by and between the undersigned parties as follows: 1. Paragraph 3 of the Agreement is modified to read as follows: Term. This contract begins on the Effective Date and ends on 06/30/2025 (“Contract Time”), unless extended or terminated as provided herein. Time is of the essence and Contractor must have sufficient time, resources, and qualified staff to deliver the Services as required. Contractor must promptly notify City of any actual or potential delays to afford the Parties adequate opportunity to address or mitigate such delays. The City’s appropriate department head or the City Manager may extend the Contract Time through a written amendment to this Agreement, provided such extension does not include additional contract funds. Extensions requiring additional contract funds are subject to the City’s purchasing policy. 2. Except as expressly modified herein, all other terms and covenants set forth in the Agreement shall remain the same and shall be in full force and effect. SIGNATURES CONTINUE ON THE FOLLOWING PAGE 2 IN WITNESS WHEREOF, the parties hereto have caused this modification of Agreement to be executed. CITY OF CUPERTINO By Title Date APPROVED AS TO FORM City Attorney ATTEST: City Clerk Date ABOLI JAYDEEP RANADE By Title Date EXPENDITURE DISTRIBUTION Item PO Number Amount Base Amount 2023-48, 2024-109 10,000.00 Amendment 1 0.00 - - 10,000.00 Fitness Instructor Jun 26, 2024 Christopher D. Jensen Director of Parks and Recreation Jun 27, 2024 Jun 27, 2024 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/21/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Maguire Insurance Agency, Inc. FWI 1 Bala Plz Ste 100 Bala Cynwyd, PA 19004-1401 610.617.7900 CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Philadelphia Indemnity Insurance Company 18058 INSURED Aboli Ranade INSURER B : INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:REVISION NUMBER : THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY)LIMITS A X COMMERCIAL GENERAL LIABILITY X 06/18/2024 06/18/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence)$100,000 X PROFESSIONAL LIABILITY MED EXP (Any one person)$2,500 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $3,000,000 X POLICY PROJECT LOC PRODUCTS - COMP/OP AGG $3,000,000 OTHER SAM AGGREGATE SAM OCCURENCE $300,000 $100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)$ ANY AUTO BODILY INJURY (Per person)$ OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY (Per accident)$ HIRED AUTOS ONLY NON-OWNED AUTOS ONLY PROPERTY DAMAGE (Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $$ Y / N PER STATUTE OTHER N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) It is understood and agreed that the following entity is added as an additional insured but only with respect(s) to the operations of the named insured except that liability resulting from the additional insured's sole negligence. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Cupertino, Its City Council, Boards and Commission, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants 10300 Torre Ave Cupertino, CA 95014-3202 AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of Cupertino, Its City Council, Boards and Commission, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants 10300 Torre Ave Cupertino CA 95014-3202 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1.In the performance of your ongoing operations; or 2.In connection with your premises owned by or rented to you. 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 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. CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE Form: Tysers SafeGuard 2021 - primary Policy Number: Unique Market Reference: Renewal of: Named Insured: City of Cupertino – Parks and Recreation Department, Public Works Department Principal Address: 10300 Torre Avenue, Cupertino, CA 95014 Policy Period: From: 1st July 2023 To: 1st July 2024 Both dates at 12:01 a.m. Local Time at the Principal Address stated in Item 1. Limit of Liability: a) USD 5,000,000 in the aggregate during the policy period for all claims brought by or on behalf of each victim, and b) USD 5,000,000 in the aggregate during the policy period for all claims brought by or on behalf of all victims and separately: c) USD 75,000 in the aggregate during the policy period for all safeguard costs resulting from all circumstances Such Limit of Liability shall be in addition to the overall Limit of Liability stated in a) and b) above. Retention: USD 35,000 any one Victim Optional Extension Period: 12 months Additional premium of 100% of the annual premium plus applicable taxes, provided no claims and/or circumstances have been reported to the insurance company. In the event any claims and/or circumstances have been reported to the insurance company, the additional premium for the 12 month optional extension period will be determined by the insurance company at the time this Policy is not renewed or replaced by the insurance company Premium: USD 34,650 to be paid within 25 days of attachment Notification pursuant to Clause IX. shall be given to: Beazley Group Attn: Claims Group 30 Batterson Park Road Farmington, CT 06032 claims@beazley.com or Other Notices: To report a circumstance under the Safeguard Additional Coverage, Call +1 844 285 4700 where a service representative will be available 24 hours a day, seven days a week Retroactive Date: 1st July 2018 Pending or Prior Litigation Date: 1st July 2018 Service of Suit: Service of process in any suit shall be made upon: Lloyd’s America, Inc. Attention: Legal Department 280 Park Avenue, East Tower, 25th Floor New York, NY 10017 Governing Law: New York Conditions: Application Dated: 26th June 2023 California Surplus Lines Notice California Complaints Notice Small Additional or Return Premiums Clause - NMA 1168 Nuclear Incident Exclusion Clause-Liability-Direct – NMA 1256 Radioactive Contamination Exclusion Clause-Liability - NMA 1477 War and Terrorism Exclusion – NMA 2918 US Terrorism Risk Insurance Act of 2002 as amended New & Renewal Business Endorsement – LMA5389 Several Liability Notice – LMA5096 Sanctions Limits Clause - LMA 3100 Tysers SafeGuard 2021 - Risk Management & Response Solutions Cyber Acts Clarification U.S Classification: Surplus Lines Broker and State filed in: Risk Placement Services, 2850 Golf Road, Rolling Meadows, IL 60008 License Number: 0C66724 State of Filing: CA Brokerage: 20% or same net equivalent downwards, plus taxes as applicable Information: Employees – 235 Contractors – 90 Exposure Units – 70,000 Nature of Business – Municipality Underwriting Security: 100% Lloyd’s (Information About Lloyd's) Updated 06/23/21 EXHIBIT C AFFIDAVIT OF NO EMPLOYEES State of California County of Santa Clara City of Cupertino I, the undersigned, declare as follows: I am an independent contractor and the owner of Aboli Jaydeep Ranade. I wish to enter into a services contract with the City of Cupertino. I am fully aware of the provisions of section 3700 of the California Labor Code, which requires every employer to provide Workers' Compensation coverage for employees in accordance with the provisions of that Code. I am also aware that I must provide proof of workers’ compensation insurance to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the City of Cupertino’s contract. I hereby certify that I do not have any employees nor will I have any employees working for me or my business during the term of any service contract with the City of Cupertino. I am not required to have Workers’ Compensation insurance. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on this ____day of ____________, 2024, at , California. ______________________________ PRINT NAME ______________________________ SIGNATURE 26 June Cupertino Aboli Ranade Fitness Instructor Final Audit Report 2024-06-27 Created:2024-06-25 By:Webmaster Admin (webmaster@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAtm2Bb6bAOsksZfgWEhh3ODUx9NfxzaRn "Fitness Instructor" History Document created by Webmaster Admin (webmaster@cupertino.org) 2024-06-25 - 10:39:55 PM GMT- IP address: 35.229.54.2 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2024-06-25 - 10:40:57 PM GMT Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2024-06-25 - 10:46:54 PM GMT - Time Source: server- IP address: 71.204.144.228 Document emailed to for signature 2024-06-25 - 10:46:56 PM GMT Email viewed by 2024-06-26 - 4:27:39 AM GMT- IP address: 104.28.111.131 Signer entered name at signing as Aboli Ranade 2024-06-27 - 0:28:02 AM GMT- IP address: 67.188.107.187 Document e-signed by Aboli Ranade ( Signature Date: 2024-06-27 - 0:28:04 AM GMT - Time Source: server- IP address: 67.188.107.187 Document emailed to Christopher Jensen (christopherj@cupertino.org) for signature 2024-06-27 - 0:28:06 AM GMT Email viewed by Christopher Jensen (christopherj@cupertino.org) 2024-06-27 - 0:29:26 AM GMT- IP address: 104.47.73.254 Signer Christopher Jensen (christopherj@cupertino.org) entered name at signing as Christopher D. Jensen 2024-06-27 - 0:29:48 AM GMT- IP address: 136.24.22.194 Document e-signed by Christopher D. Jensen (christopherj@cupertino.org) Signature Date: 2024-06-27 - 0:29:50 AM GMT - Time Source: server- IP address: 136.24.22.194 Document emailed to Rachelle Sander (rachelles@cupertino.org) for signature 2024-06-27 - 0:29:52 AM GMT Email viewed by Rachelle Sander (rachelles@cupertino.org) 2024-06-27 - 3:07:47 PM GMT- IP address: 104.47.73.126 Document e-signed by Rachelle Sander (rachelles@cupertino.org) Signature Date: 2024-06-27 - 3:08:05 PM GMT - Time Source: server- IP address: 64.165.34.3 Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature 2024-06-27 - 3:08:07 PM GMT Email viewed by Kirsten Squarcia (kirstens@cupertino.org) 2024-06-27 - 5:04:42 PM GMT- IP address: 104.47.73.126 Document e-signed by Kirsten Squarcia (kirstens@cupertino.org) Signature Date: 2024-06-27 - 5:04:51 PM GMT - Time Source: server- IP address: 64.165.34.3 Agreement completed. 2024-06-27 - 5:04:51 PM GMT