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18-001 Deborah Hall CITY OF No. is FY2018-23 CUPERTINO RECREATION SERVICES AGREEMENT 1. Parties. T1-ds contract is made and entered into as of 7/1/2018 ("Effective Date'),by and between the City of Cupertino, a municipal corporation ("City"), and with DEBORAH HALL, ("Contractor"), a SOLE PROPRIETOR for BEADING INSTRUCTION. 2. Services. Contractor agrees to provide the Services included in the Scope of Work and in accordance with the Schedule of Performance attached in Exhibit A. 3. Term. This contract begins on the Effective Date and ends on 6/30/2023 ("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. 4. Compensation. City will pay Contractor for satisfactory performance of the Services an amount that will based upon actual costs but that will be capped so as not to exceed$11,900 BETWEEN 7/1/18 AND 6/30/19; $11,900 BETWEEN 7/1/19 AND 6/30/20; $11,900 BETWEEN 7/1/20 AND 6/30/21; $11,900 BETWEEN 7/1/21 AND 6/30/22; $11,900 BETWEEN 7/1/22 AND 6/30/23 ("Contract Price"), based upon the Scope of Services,budget,performance schedule, and rates included in Exhibit A. The maximum compensation includes all costs,expenses and reimbursements and will remain in place even if Contractor's actual costs exceed the capped amount. Contractor must submit invoices and the information required in Exhibit A in order to receive payment. City will compensate Contractor within 30 days after approval of written invoices. Invoices are subject to review and audit by City during regular business hours upon 24-hours' notice. Contractor must maintain complete and accurate records of payrolls, expenditures, disbursements and other cost items charged to City or establishing the basis for an invoice, for a minimum of four(4) years from the date of final payment. 5. Independent Contractor.Contractor is an independent Contractor and not an employee, partner, or joint venture of City. Contractor is solely responsible for the means and methods of performing the Services and for the persons hired to work under this Agreement.No civil service status or other right of employment will be acquired by virtue of Contractor's performance of the Services. Contractor is not entitled to City's health benefits, worker's compensation or any other benefit. Contractor must have the skills and qualifications to perform the Services in a competent and professional manner. Contractor will supply all tools, materials and equipment required to perform the Services under this Contract. Contractor is responsible for obtaining permits and licenses required by law and must obtain a City business license. Recreation Services Agreement/Rev. 3-27-2018 Page 1 of 6 6. Proprietary/Confidential Information. To the extent Contractor may have access to private or confidential information owned or controlled by the City, Contractor agrees to treat it confidential and use it solely to perform this Agreement. Contractor must exercise the same standard of care to protect City information as a reasonably prudent Contractor would use to protect its own proprietary data. 7. Ownership of Materials.To the extent Contractor prepares written material, drawings or data in connection with this contract, City will have the property rights to those materials and all copyrights,if any, to such work product will constitute City property. 8. Records. Contractor must maintain complete,accurate, and detailed accounting records relating to its performance in accordance with generally accepted accounting principles and procedures. The records must include detailed information about Contractor's services, benchmarks, deliverables and costs/fees,and must be made reasonably available to City.The records and supporting documents must be kept separate from other files and maintained for four years from the date of City's final payment. 9. Assignment. This Contract is not assignable. Contractor may not substitute another or transfer any rights or obligations under this Contract without prior written approval of City.Only those persons whose names are included in Exhibit A may perform the Services. 10. Publicity and Signs. Any publicity generated by Contractor related to this contract or the Services during the Contract Time and for one year thereafter must reference City contributions. The words "City of Cupertino" shall be displayed in all pieces of publicity, including flyers, press releases, posters, brochures, public service announcements, interviews and newspaper articles. No signs may be posted,exhibited or displayed on-or about City property,-except signage required by-law or under this Agreement without prior written approval from City. 11. Indemnification. To the fullest extent allowed by law and except for losses caused by the sole negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend, and hold harmless the City, its City Council, boards and commissions, officers, officials, employees, agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal counsel acceptable to City, from and against any liability for damages, claims, actions, causes of action, demands, charges, losses, costs and expenses (including attorney fees,legal costs and expenses related to litigation,arbitrations, administrative and regulatory proceedings), of every nature, arising out of or in any way related to Contractor's or Contractor's agents performance of this contract or the Services. This includes but is not limited to Liability resulting in personal injury, death, property damage, or economic losses. Contractor must pay any costs City may incur in enforcing this provision and must accept a tender of defense upon receiving notice from City. Contractor's payments may be deducted or offset to cover any money the City lost due to a claim or counterclaim arising out of this Contract. 12. Insurance. Contractor shall comply with the insurance requirements in Exhibit B. City will not execute the Agreement until it has received and approved satisfactory certificates of insurance and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole discretion may purchase insurance and deduct the costs from payments to Contractor,or terminate the contract. Recreation Services Agreement/Rev. 3-27-2018 Page 2 of 6 13. Compliance with Laws and Other City Requirements. Requirements for all Contracts. This contract is subject to local, state and federal laws and regulations prohibiting discrimination,including Title VII of the Civil Rights Act of 1964,the California Fair Employment Practices Act,the Americans with Disabilities Act of 1990,and other laws that pertain to fair employment and anti-discrimination practices. Contractor must comply with labor laws pertaining to prevailing wages, working hours, overtime, payroll records, and other requirements imposed by the Department of Industrial Relations.If Contractor does not have employees,it must sign the Affidavit of No Employees, attached as Exhibit C. Contractor is responsible for verifying employment eligibility of employees pursuant to the Immigration Reform and Control Act of 1986. Contractor must comply with conflict of interest laws and regulations applicable to this Agreement and avoid conflicts of interest. Contractor may be required to file a conflict of interest form for engaging in governmental decisions or serving in a staff capacity,and is hereby advised to review the requirements of California Political Reform Act and the California Code of Regulations. Services may only be performed by persons who are not employed by City and who do not have a contractual relationship with City other than this contract. Contractor agrees to abide by City policies and administrative rules prohibiting gifts to City officials and employees. Additional Requirements for Services Provided to Minors: Contractor and its employees who provide services Colder this Agreement must comply with these additional requirements: A. Undergo fingerprinting and a criminal background check and verify all employees providing services under this contract have met this requirement. B. Complete a Tuberculosis screening test as required by law and as set forth in Exhibit D. C. Comply with the Mandatory Reporting under California Penal Code 11164-11174.3 and with the protocols, reporting, and training required under California Health and Safety Code Section 124235, A132007, and other laws pertaining to concussion evaluation,removal from play, and return to play protocols. (Refer to Center for Disease Control & Prevention, https://www.cdc.gov/headsul2/index.htn l). D. Submit required forms and acknowledgments included in Exhibit D, and ensure its each participant is provided with a concussion information sheet, signs and returns the forms to the City as required by Health and Safety Code Section 124235. Require coaches and administrators to successfully complete the concussion and head injury education at least once either online or in person, before supervising a participant. Contractor shall offer training, educational materials, or both to each Contractor administrator on a yearly basis. (Training resources are available at the Center for Disease Control&Prevention(link cited above). E. If providing instruction, Contractor must acknowledge and comply with all requirements set forth in the Recreation&Community Services Instructor Manual. Check one (if applicable): ❑ This contract requires services for children. Recreation Services Agreement/Rev. 3-27-2018 Page 3 of 6 i ® This contract currently does not require services for children. If in the future, services for children are required,the contract will require a'written amendment' to include the appropriate insurance coverages as required in'Exhibit B—Insurance Requirements for Recreation Contracts', proof of finger printing and additional requirements under Paragraph 13. The contract amendment will also require the approval of the Director of Recreation and Community Services and City Attorney. 14. Coordination of Services. The Parties designate the following persons as Services Coordinators with the responsibility to oversee the delivery of Services in accordance with the terms of this Agreement. Contractor's designation and any substitution are subject to City approval. For City: For Contractor: Name:Jason Bisely Name: Deborah Hall Position:Recreation Coordinator Position: Instructor Contact:jasonb@cupertino.org;408.777.3150 Contact: 15. Abandonment. City may abandon or postpone the Activity or Program and will notify Contractor as soon as possible. Contractor will be paid for satisfactory Services rendered through the date of abandonment upon submission of final invoices approved by City. 16. Termination. City may terminate this contract for cause or without cause at any time and will notify Contractor as soon as possible.Contractor will be paid for satisfactory services rendered through the date of termination upon submission of final invoices approved by City. 17. Governing Law,Venue and Dispute Resolution.This contract is governed by the laws of the State of California. Any legal actions or proceedings filed against City in connection with this contract must comply with the government claims filing requirements and must be filed with the Superior Court for the County of Santa Clara, State of California. At City's request, Contractor is required to continue to provide Services pending resolution of any dispute. If the Parties elect arbitration, the arbitrator's award must be supported by law and substantial evidence and include detailed written findings of law and fact. 18. Attorney Fees. If City is required to pursue litigation,arbitration or other administrative or regulatory proceeding to enforce its rights or the terms of this Agreement, the prevailing party will be entitled to reasonable attorney fees and costs. This Section survives this Agreement. 19. Third Party Beneficiaries.There are no third party beneficiaries under this Contract. 20. Waiver. Neither acceptance of Services nor payment thereof constitutes a waiver of any contract provision. City waiver of a breach shall not constitute waiver of another term, provision, covenant or condition, or a subsequent breach, whether of the same or a different character. 21. Entire Agreement.This Agreement and all referenced Exhibits are hereby attached and incorporated into the Agreement by this reference and represent the full and complete understanding as to those matters contained herein,and supersede any other contract or understanding,either oral or Recreation Services Agreement/Rev. 3-27-2018 Page 4 of 6 written,between the Parties.This Agreement may not be modified or amended except in writing signed by both Parties.If there is any inconsistency between the main contract and any attachments or exhibits thereto,the main contract shall prevail. 22. Inserted Provisions.Each provision or clause required by law or this contract is deemed to be included and will be inferred herein. Either party may request an amendment to cure any mistaken insertion or omission of a required provision. 23. Headings. The headings are for convenience only and are not a part of the contract or intended to affect,limit or amplify the terms or provisions of this Agreement. 24. Severability/Partial Invalidity. If any contract term or provision, or their application to a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or provision shall remain in force and effect to the extent allowed by such ruling. All other contract terms and provisions and their application to specific situations will remain in full force and effect. 25. Survival.All provisions which by their nature must continue after the Agreement ends, including without limitation Indemnification, Insurance, Ownership of Materials,Records, Governing Law and Attorney Fees,will survive the expiration or termination of this Agreement. 26. Notices.All notices and instruments pertaining to material provisions of this contract or significant disputes which are required by law or under this contract to be in writing must be sent to the persons listed below. The notices will be deemed effective on the date of personal delivery or the date confirmed by a reputable overnight delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid, registered or certified, or the next business day following electronic submission. To City of Cupertino: To Contractor: Office of the City Manager Email: jasonb@cupertino.org 27. Validity of Contract. This contract is valid and enforceable only if it complies with the provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or authorized designee, and is approved for form by the City Attorney's Office. 28. Execution. The person executing this contract on behalf of Contractor represents and warrants that Contractor has full right, power, and authority to execute this contract and to carry out all actions and services required. This contract constitutes a legally binding obligation of Contractor, and may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. Recreation Services Agreement/Rev. 3-27-2018 Page 5 of 6 IN WITNESS WHEREOF,the parties have caused this contract to be executed. CONTRACTOR CITY OF CUPERTINO Deborah - A Municipal Corporation By Na.,rr_te �J�Z�� Ce��'f es 9 Nam�l�I Title�1,:tt t-LA C:76 Title Date Date Tax I.D. No.: Refer to W-9 APPROVED AS TO FORM: ATTEST: �2, GRACE SCHMID *ertinoty Attorney/ "- City Clerk ContractlEncumbered Amount:$59,500 Account No.:100-62-623 700-702 Recreation Services Agreement/Rev. 3-27-2018 Page 6 of 6 EXHIBIT A SCOPE OF WORK, PERFORMANCE AND PAYMENT SCHEDULES The CONTRACTOR will provide BEADING INSTRUCTION in,but not limited to,the following: BEADING BEGINNING KUMIHIMO BEGINNING Location and Time of CONTRACTOR Services: Refer to the Senior Center Newsletters dated JULY/AUGUST 2018, SEPTEMBER/OCTOBER 2018, NOVEMBER/DECEMBER 2018,JANUARY/FEBRUARY 2019, MARCH/APRIL 2019,MAY/JUNE 2019,JULY/AUGUST 2019,SEPTEMBER/OCTOBER 2019, NOVEMBER/DECEMBER 2019, JANUARY/FEBRUARY 2020,MARCH/APRIL 2020, MAY/JUNE 2020,JULY/AUGUST 2020, SEPTEMBER/OCTOBER 2020, NOVEMBER/DECEMBER 2020,JANUARY/FEBRUARY 2021, MARCH/APRIL 2021,MAY/JUNE 2021,JULY/AUGUST 2021, SEPTEMBER/OCTOBER 2021, NOVEMBER/DECEMBER 2021,JANUARY/FEBRUARY 2022, MARCH/APRIL 2022, MAY/JUNE 2022,JULY/AUGUST 2022,SEPTEMBER/OCTOBER 2022, NOVEMBER/DECEMBER 2022, JANUARY/FEBRUARY 2023,MARCH/APRIL 2023, MAY/JUNE 2023 for agreed upon dates,times, and class locations. The City, at its sole discretion,may change the agreed terms. Compensation for CONTRACTOR Services: Contractor shall be compensated for services performed pursuant to this Agreement. Compensation shall consist of the following: EIGHTY FIVE PERCENT(85%) OF REVENUE GENERATED PER SESSION BASED ON FINAL CLASS ROSTER. A TWENTY-FIVE ($25) DOLLAR ADMINISTRATION FEE WILL BE DEDUCTED FROM THE FIRST PAYMENT. CONSULTANT SHALL PROVIDE ALL TEACHING SUPPLIES SUCH AS,BUT NOT LIMITED TO,DRY ERASE MARKERS, ERASERS,AND HANDOUTS. CONSULTANT PAYS FOR COPY SERVICE AT THE SENIOR CENTER AT$0.10 PER PAGE.The total compensation to the Contractor shall not exceed$59,500. Eligible Participant Minimum and Maximums for CONTRACTOR Services: Minimum: 7 Maximum: 20 If less than the required minimum number of participants enroll in and pay for a particular class as identified in the schedule before the class is scheduled to start, the City may cancel the particular class and/or terminate this Agreement without additional notice or payment to Contractor. List of all Contractor Employees working for the City of Cupertino (if no Employees,identify "self'): SELF Performance of CONTRACTOR Services: In the case Contractor unilaterally cancels performance of a class, camp, activity or service without City approval, City reserves the right to immediately and without notice cancel the remainder of programs/services offered and or performed by Contractor. The Contractor shall follow all guidelines pertaining to registration procedures as listed in the quarterly recreation schedule.Participants may not take part in the program unless they are listed on the class roster or can show proof of enrollment. All participants and volunteers need to complete the City's Waiver of Liability form prior to taking part in the program. If applicable, contractors who are responsible for supervising minors must remain with the class until a parent of legal guardian has arrived and all minors are released to them. In the event of an injury occurring to a participant, the Contractor will notify the City within 1 hour and complete an Incident Report in the form approved by the City. The Incident Report must be submitted to the City within 24 hours of the injury occurring. Exhibit B Insurance Requirements for Recreation Contracts As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance for the duration of the contract against claims arising from or in connection with Contractor, its agents, representatives, employees or subcontractors Services under this Agreement. Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as: 1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply separately to this project/location(CG 25 03 or 25 04) or be twice the required occurrence limit. 2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos, Code 8 (hired) and 9 (non-owned), with limits no less than$1,000,000 per accident for bodily injury and property damage. ❑ Required if automobile is used to perform work under this contract. Otherwise, proof of Contractor's personal auto insurance with limits required by state law suffices. Contractor shall not transport or use its personal vehicle to transport participants or perforin work under this contract. 3. Workers' Compensation: As required by the State of California, with Statutory and Employer's Liability Insurance limits of no less than$1,000,000 per accident for bodily injury or disease. ❑ Required if Contractor has employees. If no employees, Contractor must sign Affidavit of No Employees. 4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/services involving minors, (i.e., after school activities, recreational programs, athletics, study/training events and transportation of minors). Coverage may be included under General Liability or be obtained in a separate policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply separately to this contract or be twice the required occurrence limit. ❑ Required if Contract involves services to children. Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance. Self-Insured Retentions: Self-insured retentions must be approved by City. City may require Contractor to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language must provide, or be endorsed to provide, that the self- insured retention may be satisfied by either the named insured or City. Acceptability of Insurers: Insurance must be issued by insurers acceptable to City and licensed to do business in the State of California,with an A.M.Best's financial strength rating of"A"or better and a financial size rating of"VII"or better. OTHER INSURANCE PROVISIONS: The CGL policy must contain, or be endorsed to contain, the following provisions: 1. The City, its City Council, boards and commissions, officers, officials, employees, agents, servants and volunteers are to be covered as additional insureds with respect to liability arising out of work or Exh.B Insurance for Recreation Contracts Updated 3-26-18 1 operations performed by or on behalf of the Contractor including materials, parts or equipment furnished in connection with such work or operations. 2. Contractor's insurance shall be primary insurance coverage at least as broad as ISO CG 20 0104 13 as respects the City, its officers,officials, employees, agents,and volunteers. 3. The Insurance Company agrees to waive all rights of subrogation against the City, its elected or appointed officers, officials,agents,and employees for losses paid under the terms of any policy which arise from work performed by Contractor for City. This provision also applies to the Contractor's Workers' Compensation policy. 4. Each insurance policy required by this contract shall provide that coverage shall not be canceled, except with notice to the City. Primary Coverage: The Additional Insured coverage under Contractor's policy shall be primary non- contributory and at least as broad as ISO CG 20 01 04 13 as respects the City and all the insureds/indemnitees. If the limits of insurance required are satisfied in part by Umbrella/Excess Insurance, the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a "primary and non-contributory"basis for the benefit of the Additional Insureds before City's own insurance is triggered. Notice of Cancellation: Each insurance policy shall provide that coverage shall not be canceled or allowed to expire without written notice to City 30 days in advance or 10 days in advance if due to non-payment of premiums. Such notice must be sent to City via email or certified mail to the attention of the City Manager. Waiver of Subrogation: Contractor grants City a waiver of any right to subrogation which any insurer of said Contractor may acquire against City by virtue of payment of any loss under such insurance. Contractor will obtain any endorsement that may be necessary to effect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. Verification of Coverage:Contractor shall furnish the City with original certificates and amendatory endorsements effecting coverage required by this clause. All certificates and endorsements are to be received and approved by the City before work commences. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements affecting the coverage required by these specifications,at any time.At a minimum Contractor must provide acceptable copies of the policy declarations and endorsement page verifying the required insurance coverages. Homeowner's Insurance: Contractor's homeowner's liability insurance may provide coverage sufficient to meet these requirements. Contractor should provide these requirements to his or her agent to confirm and provide verification to City. Special Events Coverage:Insurers may provide special events coverage for a reduced fee, or City may be able to offer this coverage. Contractor should contact the City Manager's Office for information or assistance. Special Risks or Circumstances:City reserves the right to modify these requirements based on the nature of the risk,prior experience, insurer,coverage, or other special circumstances. Exh.B Insurance for Recreation Contracts Updated 3-26-18 2 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 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 VYICU 2018, atCoClr,,- A c d California. PRINT NAME SIGNATURE EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 6365-19555990001581 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED) Alliant Insurance Services,Inc.in conjunction with City of Cupertino Apex Insurance Services P.O.Box 6450 Newport Beach,CA 92658 License No:OC 36861 NAMED INSURED(EVENT HOLDER): EVENT INFORMATION: Deborah Hall TYPE: Arts And Crafts(Various) LOCATION: Cupertino Senior Cenler,21251 Stevens Creek Blvd,Cupertino,CA 95014 *Liquor Liability Yes No **Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless amended as described in Special Conditions. INSURANCE CARRIER:Evanston Insurance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES: EFFECTIVE: January 01,2018 EXPIRATION: January 01, 2019 COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE Aggregate Limit $2,000,000 Products&Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal&Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance: Medical Payments(Any One Person) 5,000 MEGL1643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,00053,000,000 ❑ $2,000,00052,000,000 Property Damage(If purchased) No Property Damage Coverage The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: 01/19/2018 POLICY NUMBER: SEP41026 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional InsuredPerson(s) Or Organization(s): City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees,Agents, Servants, Volunteers and Consultants For Certificate No.: 636519555990001581 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 B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. 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. CG 20 26 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 /� CSM I�urance Exchange Automobile Policy Declarations i(����/� P.O.Box 22221 Oakland,CA 94623-2221 Please keep with your policy.See Important Notice on reverse. Insurance For questions or changes call:(800)922-8228 Page 1 of 1 1.Name and Address of Insured '��I��I����II'VIII'I'I111�11111'I�It�rl��ll�ll�l�l��tllllll�ll�ll O Tlpera`i°°s Renewal Certificate nat-ss 11-292017 t DEBORAH HALL Nli n-r Shred 2004 653312 01 A.M.Standard Time at the address of the z Named Insured,but not prior to the time applied Your 01-02-2018 for w,if this is a replacement declarations,not U Policy prior to the time cov_aage change was requested. J Period To 12'01 A.M.Standard Time at the address of the d 01-02-2019 Named Insured. Alternate Address Occupation Alternate Number Tekephone Number Health Care Professional (999)894-5206 Item Make Model Yr Body Type Vehicle Identification No. Name tA 1 do not tJJ W necessarily _ ] correspond NJ be to principally G operated vehicles lab Coverage --__-_---_-____.....lytimis ...-.__item t .yt....................... ..... .................-._._....... ._.._...............-------.-------- ._._ Each Person Each Occurrence Deduducribke Premium Deductible Premium Deductible Premium Dedictible Aemium Bodily Injury 25,000 50,000 $188 ....................................................................................................... Medical Payments No Coverage No Coverage ......................................................------------------..... ........................ Uninsured Motorists 25,000 50,000 $41 Property Damage 50,000 E $319 ............................................... ...................................... comprehensive Actual Cash Value Less Deductible 100 $44 Full Comprehensive Safety Glass Endorsement ($0 deductible) NO COV ------------------ Collision Actual Cash Value Less Deductible 1,000 $261 Enhanced Transportation Expense $25 per day/$750 aggregate $28 All Risks Actual Cash Value Less Deductible No Coverage Vehicle Loan/Lease Protection Endorsement No Coverage New Car Added Protection Endorsement No Coverage Original Equipment Manufacturer Parts(OEM)Endorsement No Coverage Ride-sharing Coverage Endorsement No Coverage TOTAL PREMIUM PER VEHICLE ➢ $881 *Automobile Death Benefits $15,000 per deceased insured person Premium $3 Premium Summary This is not a bill. CA Surcharge:$0 CA Special Fraud Assessment Fee:$1.76 Total Premium: $885.76 Total Premium shown is for the Member Advantagelm Program. EXCLUSIONS There is no coverage provided by this Policy while the following individual(s)operate a motor vehicle: None Schedule of Changes N W ID z a x U 55 1500 12 15 11-242017 - M56 0210 (Continued on back) Item Rated Driver thw Safety Record Ws Ddv E1p Pmr Ann Miles Future Ann Miles Veh Garage Zp Vehicle Usage Gender Marital 1 DEBORAH HALL W See final page l7 Q for explanation 1A o codes. W 1A z Discounts: :3 Mature Driver:None. Multi Car:None. NGood Driver:Item(s) 1. New Driver:None. o Multi Policy:None. Good Student:None. hUNITED SERVICES CREDIT UNI You may qualify for other products LU lm PO BOX 23883 and discounts.For more info call a OAKLAND CA 94623 your Insurance Agent s N Paul T Osegueda o (510)360-3360 IMPORTANT NOTICE:THIS IS A PART OF YOUR DECLARATIONS The insurance afforded is only with respect to such of the preceding coverages as are indicated by specific premium charge or charges.The limit of the Exchange's liability under each such coverage shall be as stated herein,subject to all the terms of the policy.The purpose for which the automobile is to be used is pleasure or business,subject to the exclusions in the policy,including the exclusion for wholesale and retail delivery. RENEWAL CERTIFICATE-Extends this policy for the period shown under Policy Period upon payment of the premium. AMENDED DECLARATIONS-In consideration of the premium adjustment indicated herein this policy is hereby amended only with respect to such changes as are indicated in the schedule of changes.The limit of the Exchange's liability under such amended coverage shall be as stated herein. LOSS PAYEE(S)-Any loss under Physical Damage coverages is payable as interest may appear to the named insured and the Loss Payee in accordance with the loss payable agreement. RATING INFORMATION DISCLOSURE EXPLANATION (From Discounts/Messages Section on Previous Page) ITEM(ITEM NUMBER): Item number is the number assigned to the vehicle shown on the Declarations. RATED DRIVER:The driver assigned to a vehicle whose attributes(e.g.,years driving experience,driving safety record,gender,and marital status)are used to develop the premium. DRIV SAFETY RECORD(DRIVING SAFETY RECORD):The total number of points assessed the driver for "principally at fault chargeable accidents"with or without injury and/or vehicle code violation convictions(tickets).A "principally at fault chargeable accident"occurs when the driver of a vehicle is at least 51%at fault for an accident and the total monetary damages(whether paid or not)in the accident exceed: • $750 or the accident resulted in death for losses occurring prior to 12/11/11 • $1,000 or the accident resulted in death for losses occurring 12/11/2011 or after Additional information on the number and types of incidents can be provided on request. Carriers use different point count systems for rating purposes.The number of points shown on your declarations would not necessarily match the number of points assigned by another carrier. YRS DRIV EXP(YEARS DRIVING EXPERIENCE):The number of years a driver has been licensed to drive a motor vehicle anywhere in the world. However,a driver must have at least 18 months current driving experience in the United States, U.S.Territories,or Canada, before foreign country driving experience can be counted. PRIOR ANN MILES(PRIOR ANNUAL MILES DRIVEN):The estimated number of total miles a vehicle was driven during the year just past. FUTURE ANN MILES(FUTURE ANNUAL MILES DRIVEN):The estimated number of total miles a vehicle will be driven in the coming year. VEH GARAGE ZIP(VEHICLE GARAGED ZIP CODE):The ZIP code of the location where the vehicle is garaged. VEHICLE USAGE:Vehicles are assigned to one of five usage designations: Business Use,Work Commute,Farm Use,Farm Business Use or Pleasure. GENDER: "M"stands for Male and "F"stands for Female. MARITAL(MARITAL STATUS): "M"stands for Married,and "S" stands for Single. DISCOUNTS:A reduced rate applies for each Discount listed. 55 1500 12 15 11-232017 09957 0210