18-001 Juan He (2) FIRST AMENDMENT TO AGREEMENT 17-001
BETWEEN THE CITY OF CUPERTINO AND JUAN HE
FOR DANCE INSTRUCTION
This First Amendment to Agreement 17-001 between the City of Cupertino and Juan
He, for reference dated 6/5/2018, is by and between the CITY OF CUPERTINO, a municipal
corporation (hereinafter "City") and Juan He, a Sole Proprietor ("Consultant") whose
address is Cupertino, CA 95014, and is rnade with reference to the
following:
RECITALS:
A. On 4/3/2018, an agreement was entered into by and between City and
Consultant (hereinafter "Agreement") for Dance Instruction. The agreement will
expire on 6/30/2020.
B. The Agreement is referred to as the "Agreement" unless otherwise indicated.
C. City and Consultant desire to modify the Agreernent on the terms and
conditions set forth herein.
NOW, THEREFORE, it is mutually agreed by and between and undersigned parties
as follows:
1. COMPENSATION
Paragraph 4 of the Agreement is rnodified to read as follows: 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 $13,000 ("Contract Price"), based
upon the Scope of Services, budget, performance schedule, and rates included in
Exhibit A-1. The maximum compensation includes a11 costs, expenses and
reimbursements and will remain in place even if Contiactor'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.
2. COMPLIANCE WITH LAWS AND OTHER CITY REQUIREMENTS
Paragiaph 13 of the Agreement is modified, adding on the language below:
Check one (if applicable):
Ox This contract requires services for childien.
❑ This contract currently does not require services for children. If in the future,
services for children are required, the contract will require a'written arnendment' to
include the appropriate insurance coverages as iequired in'Exhibit B -Insurance
Requirements for Recreation Contracts', proof of finger printing and additional
requirernents under Paragraph 13. The contract amendment will also require the
approval of the Director of Recreation and Coinmunity Services and City Attoiney.
3. The following Exhibits to the Agreement, are amended and replaced to read as
shown in t11e attachments to this Amendinent:
a. Exhibit A— 1
b. Exhibit B
c. SAM Insurance Quote
4. Except as expressly modified herein, all other terrns and covenants set forth in the
Agreement shall remain the same and shall be in fu11 force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this modification of
Agreement to be executed.
JUAN HE CITY OF CUP RTINO
By�4 -�_�! �,�.���,. �w+� ��� By
Title: Dance Instructor Title ��2��� � ��y'"
RE MMENDED FOR APPROVAL APPROV AS TO FORM
$Y a
�
T' lN1 �U V�SU1�
Cupertino A ting City Attorney
ATTEST
City Clerl< Cp< �.,�< jd'
EXPENDITURE DIS'I'RI�UTION
PO#2018-472 580-63-620 700-702
Original Contract: $1,000
Arnendment#1: $1,000
Total: $2,000
EXHIBIT A-1
SCOPE OF WORI<,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide DANCE INSTRUCTION in,but not lirnited to,the following:
CONTEMPORARY&CHINESE DANCE
Location and Tirne of CONTRACTOR Services:
Refer to the Recreation Sclledule dated SUMMER 2018-SPRING 2020 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 coinpensated for services performed pursuant to this Agreeinent. Compensation
shall consist of the following: 65% of resident fees & drop-u1 fees. The total compensation to the
Contractor shall not exceed$13,000. (FY 17/18=$2000;FY 18/19=$5500;FY 19/20=$5500)
Eligible Participant Minirnurn and Maxirnurns for CONTRACTOR Services:
Mulimwn: 10
Maximum: 20
If less than the required minimuin number of participants enroll in and pay for a particular class as
identified in the schedule before t11e class is scheduled to start, the City inay cancel the particular class
and/or terinuzate t11is Agreeinent without additional notice or payment to Contractor.
List of a11 Contractor Ernployees working for the City of Cupertino (if no Ernployees,identify
"self"):
self
Performance of CONTRACTOR Services:
I�1 fl1e case Contractor wlilaterally cancels performance of a class, camp, activity or service witllout
City approval, City reserves the right to im�nediately and without notice cancel t11e remainder of
programs/services offered and or performed by Contractor.
Tl1e Contractor shall follow all guidelines pertauiing to registration procedures as listed u1 the
quarterly recreation schedule. Participants may not take part in the prograin unless they are listed on
the class roster or can show proof of enrollment. All participants and voltuzteers need to complete the
City's Waiver of Liability form prior to taki�lg part u1 the prograin. If applicable, contractors who are
responsible for supervisuzg muzors inust remain with t11e class until a parent of legal guardian 11as
arrived and all ininors are released to them.
In the event of an injury occurring to a participant, tlle Contractor will notify the City within 1 hour and
coinplete an I�lcident Report i�z the forin approved by the City. The I�zcident Report must be submitted
to the City within 24 hours of the injury occurring.
Exhibit B
Tizsu��a�ace Requireme�tts fo��Rec��eatio�a Cont��acts
As required by Section 12 of the Agreement, Contractor shall procure and maultain the following insurance
for the duration of the contract against claiins arisulg from or in cormection with Contractor, its agents,
representatives, employees or subconti•actors Services under tlus Agreenlent.
Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as:
1. Commercial General Liability (CGL): I�lsurance Services Office Forn1 CG 00 O1 covering CGL on an
"occurrence" basis, including property damage, bodily uljuiy and personal & advertising injury with
linuts no less than $1,000,000 per occurrence. If a general aggregate limit applies, it nlust apply
separately to tlus project/location(CG 25 03 or 25 04) or Ue twice the required occun•ence luzlit.
2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos,
Code 8 (lured) and 9 (non-owned), with liinits no less than $1,000,000 per accident for bodily injury and
property damage.
❑ Requi��ed if auto»zobile is used to perfof�nz wo��k u��der this contract.
�i7 Ot1�eNwise, ���oof.of Co�zt�actor's pe�sonal auto insurance witla lin�.its J�equi��ecl by state lc�w
suffices. Co��t��actor sl�all r�ot tra�zs�ort o�° use its pei�sor�al vel2icle to ti�ansport�articipants oN
peifo��»��vo��k uJzder this colztl�act.
3. Workers' Compensation: As required by the State of Califoi�ua, with Statutoiy and Employer's
Liability I�lsurance luizits of no less than$1,000,000 per accident for bodily injury or disease.
❑ RequiT�ed if Co�2t��acto�has e��aployees.
$Y If�zo e�n�loyees, Co��t�^actoT�l��ust sig�z Affida>>it of No Employees.
4. Sexual Abuse/117olestation: Insurance or tlie equivalent as required for activities/seivices involving
minors, (i.e., after school activities, recreational programs, athletics, study/traiiiu7g events and
transportation of minars). Coverage may be included under General LiaUility or be obtained in a sepai•ate
policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per
occui7ence. If a general aggregate lulut applies, it must apply separately to tlus contract or Ue twice the
requued occunence limit.
� Requi��ed if Cont�^act iJ�volves seJ��ices to clZiZdi�e��.
Insurance coverage required may be satisfied by a combuiation of Prunaiy and Excess/Lhllbre�la insurance.
Self-Lisured Reteritiorzs: Self-insured retentions must be a�proved Uy City. City inay require Contractor to
provide proof of aUility to pay losses and related investigations, clauil admiiustration, and defense
expenses witlun the retention. The policy language must provide, or be endorsed to �iovide, that the self-
insured retention may be satisfied by eithei•the named insured or City.
Acceptability ofl�7sur^er•s:I�Zsurance must Ue issued by insurei•s acceptable to City and licensed to do busiiiess
ii1 the State of Califoi�iia,with an A.M. Best's financial strength rating of"A"or better and a financial size
rating of"VII"or Uetter.
OTHER INSURANCE PROVISIONS: The CGL policy inust contain, or be endorsed to contain, the
following provisions:
1. The City, its City Council, boai•ds and conu7lissions, officers, officials, employees, agents, seivants
and volunteers are to be covered as additional insureds with respect to liability arising out of work or
Ex1�..B bzsurance for Rec�•eatio�z Contracts Updated 3-26-18
1
operations perfonned by or on Uehalf of the Contractor including materials, parts or equipinent
furnished in coilnection with such work or operations.
2. Contractor's insurance shall be primary insurance coverage at least as broad as ISO CG 20 Ol 04
�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
a�pointed officers, officials, agents, and employees for losses paid under the terms of any policy
which arise fiom work perfoi-nled by Contractor for City. This provision also applies to the
Contractor's Workers' Compensation policy.
4. Each ulsurance policy required Uy this contract shall provide that coverage shall not be canceled,
except with notice to the City.
Pr�i�na�y Cove�°age: The Additional I�Zsured coverage under Contractor's policy shall be prunaiy non-
contributoxy and at least as broad as ISO CG 20 O1 04 13 as respects the City and all the
insureds/indenuutees. If the linuts 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 "priinary and non-contributory"basis for the benefit of the Additional Insureds before City's
own insurance is triggered.
Ivotice of La�aceilation: �ach insurance policy shail provide inai coverage siiall not be canceieu ai-aliowed tu
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 Sub��ogation: Contractor grants City a waiver of any right to subrogation which any insurer of said
Contractor inay acquire against City by virtue of payn�ent of any loss under such ulsura�lce. Contractor will
obtain any endorsement that may Ue necessary to effect this waiver of subrogation, but tlus provision applies
regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer.
Verifrcatio�a of Coverage: Contractor shall fui77ish the City with original certificates and amendatory
endorsenlents effecting coverage required by tlus clause. All certificates and endorsements are to be received
and approved by the City before work conullences.The City reserves the right to require conlplete, certified
copies of all required insurance policies,includ'u1g endorsements affecting the coverage required Uy these
specifications, at any time.At a nunulium Contractor must provide acceptable copies of the policy
declarations and endorsement page verifying the required insurance coverages.
Hor�teow»er's Insu��ar�ce: Contractor's homeowner's liability insurance may provide coverage sufficient to
meet these requirements. Contractor should provide these requirements to lus or her agent to confinn and
provide verification to City. .
Special Ever�ts Cover�age:I�isurers may provide special events coverage for a reduced fee, or City may be
aUle to offer this coverage. Contractor should contact the City Manager's Office for infoi7nation or assistance.
- - - Sp�cial-Risks o��-Grrcu»astarzces: Cityxeserves the right to_z��adify_tllese requireule__nts vased on_t11e ilature of
the risk,prior experie�ice, insurer, coverage, or other special circumstances.
Exh.B Instu�a�7ce for Rec��eatron Cor7z��acts Updated 3-26-18
2
ARCH ��c
INTERMEDIARIES
CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE
Form: SML Safe�uard Wordin�- 623AFB00213
Policy Number: TBA
Renewal of: N/A
Named Insured: City of Cupertino—Dept of Recreation&Community Services
Principal Address: 10185 N Stelling Road, Cupertino, CA, 95014
Policy Period: From: l st July 2018 To: l st July 2019
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 for all Claims for Wrongful Acts against a11y one Victim
b) USD 5,000,000 for all Claims for Wrongful Acts against all Victir�as,but
sub-limited to:
c) USD 50,000 for all Safeguard Costs resulting from all Circumstances
Such Sub-limit of LiaUility shall be part of, and not in addition to,the overall Limit of Liability
stated in 3.b)above.
Retention:
USD 35,000 any one Victim
Premium:
USD 27,000 to be paid within 25 days of attaclunent
Notification pursuant to Clause IX. shall be given to:
Claims Department Beazley
30 Batterson Park Road,
Farmington,
CT 06032.
cl aims(a�b eazl ev.com
(860) 677 3765 (phone)
(860) 679 0247 (fax)
Retroactive I)ate:
1 S`July 2018
Pending or Prior Litigation Date:
1 St July 2018
Service of Suit:
Eileen Ridley,FLWA Service Corp., c/o Foley&Lardner LLP,
555 California Street, Suite 1700, San Francisco, CA 94104-1520
Choice of Law:
New York
Conditions:
Application Dated: TBA
Califonua Suiplus Lines Notice 1-LMA9098A
Small Additional or Return Preiniums Clause(U.S.A.)—NMA 1168
Nuclear Incident Exclusion Clause-Liability-Direct—NMA 1256
Radioactive Contamination Exclusion Clause-Liability-NMA 1477
War and Terrorism Exclusion—NMA 2918
Sanctions Liinits Clause-LMA 3100
Beazley Safex��ard Education Docuinent
Arch Safe��ard Enhancement Endorsement
U.S Classi�cation:
Surplus L'ules Broker and State filed in: TBA
License Number: TBA
Subject to:
1) Satisfactory re-signed and dated SML application within 30 days of inception
2) Confirmation of the Surplus Lines Broker. Including name of individual, company
name, address and license number
All subjectivities to be received witlun 7 working days of binding otherwise Underwriters
reserve the right to amend tenns or cancel ab initio.
Brokerage: 22.5%or same net equivalent downwards,plus taxes as applicaUle
Information: Einployees—36 full time+250 part time+63 IC's
Exposure Units—97,000
Nature of Business—Municipality
Cancellation by an Insured inay result in a short rate calculation to determine
the return premium, subj ect to 5%minimum earned of the total premium.
Underwriting
Security: 100%Lloyd's(Infoi-�nation about Llovds)
CtTY O�
No. r�s- �a
FY2018-19
CUPERTIfVO
RECREATION SERVICES AGREEMENT
1. Paxties. Tlus collhact is inade and eiztexed into as of April 3,207.8
(`BfEective D1te"),by and betweel�the City of Cuperiitlo, a mLulici�al coipo��tion("City"),aT1d fuail
He, Cuperfino, CA 95014("Coz�tractoi"),a sole�rot�rietor for dailce i�-�sliucti.oil.
2. Serviees.Contractor agrees fio provide the Services ulcliided 'uz fi11e Scope of Worlc and
i�z accordaxlce wiilz t11e Scl�.edLile of Performa�lce attached rxz Exhibit A.
3. Term.T1�is coritract begins on tlle Effective Date ai�d ends on u71e 30,2Q20
("Coiztract T�ne"), uriless exteyaded or fermi�zated as provided hereuz. Tune is of the essence at-�d
Contraefior�riust Izave sufficierlt tirne, resources, a�1d quaIified staff to deliver the Services as xequixed.
Contractor xnust prornptly 1lotify City of a11y actt.tal or potezztial cleJays to afford �11e Parties adequate
opport-u�lity to address or mitigate sucI1 delays.
4. Coxn�eitsation. City wiIl pay Contractor for satisfactory perfozzxiance of��e Services a�1
amourlt that will based upori actual costs but t�1at will be capped so as not l-o exceed$12,000("Coilfract
Price"),based upon tlze Scope of Services,budget,perforinvzce sclzedule,lnd rates izlcluded u1 Exhibit
A. TI1e ma�ciuntuz� comperlsatiozz ulcludes a11 costs, expenses a�1d reunbuise�neilfs a1�d wi1J rernaizz ui
place even if Contractor's actual costs exceed tlle capped amount.Coni�acfior mu.st subinit ulvoices and
fihe u�fornlation.required in ��1iUil-A in oxder to receive payineilt. City will coinpensate Contractor
wit1�u130 days after ap�roval o£written invoices.
Invoices are subject to review aizd audit by City durv�g regular busuless hours u�on 24-hours'
Tiotice. Contractor musl inaitltauz coLnplete and accurate records of payroIls, expenclitures,
disburseinents and otller cost itelns cllarged to Cify or establislz�lg �Ze basis for an ulvoice, for a
i�rinirrtuin of four(4)years frain fi11e date of fi�1a1 paymeill:,
5. Tnc�e�endent Confractor.Contractor is ari i�ldependeilt Co�.lf�actor�1d�Zot ai1 ein�l.oyee,
pari�iei, or joint vealt�.ue of City. Cox�tr�ctor is solely responsible for tJ.ze n1e��.s aT1d inetl2ods of
perfoxznu�.g lhe Services axzd for t11e�ersons Ilired to worl<unde.r t11is Agreeinent.No civil service status
or otller r.ig1-�t of elnploy�.ent wiJ] be acqui�ed by vutue of Contractor's�erforxnalzce of�he Services.
Cozltxacfor is liot ezztitled to City's healtll benefits, �vorker's colnpensation or �rzy otl�er benefit.
Contractor must 11ave the sl<ills a��d qualifications to perfoxan �11e Services uz a con��etent a1i.d
professiona11na1v1er. Conl-ractor will.supply all tools, lnater.ials aizd equiprnerlt required to perform
tlZe Services tulder�Zis Cont7^act. Contractor is responsible for obtai��rzg permifs a�1d licellses required
by law a�1d�riust obtain a City business license.
6. Pxoprietary/Confiden�ial Znformation.To the extellt Contractox inay 11ave access to
pravate o� corlfidential information owned or corllrolIed by t11e City, Contractor agrees to treat it
co��Hd.en�ial a11d use it soleIy to pexform�11is Agreelnelzt. Col�iracfoz tx�usf exercise the saine standard
Rec�^eation Services flg�^eenaeazt/Rev. 3-14-2018
Page 1 of 12
of care to protect City infornnation as a reasoilably prudent Contractar would use to protect its ow�1
proprietary data.
7. Ownership of Materials.To the extent Coiztractor prepa_res written inaterial, drawulgs
or data in coivlectio�l wit11 t11is conhact, City will I1ave t11e property xights to tilose inaterials and aIl
copyrights,if any,to such work product will constiEufe City�ro�erty.
8, Records.Cozltractor inust maii�tai�1 complete,accurate,and,cletailed accotuiting records
� relating to its performance u1 accorda�zce witlz geilerally accepfied accounting pruzciples �id
procedures, The records inust vacJude detailed itlformation about Coi�iractor's services, bellcl�unarks,
deliverables a�1cl costs/fees,axzd must be made reasonably available to City.The records a�1d sup�ortirlg
docLunents inust be I<ept separate froln ofller£zles and maintauled for faur years fxoin the date of City's
fulal payinent.
9. Assignmenfi.T1zis Coi�tract is not assignable.Contractoi inay rlot substitute aa1ot11er o�
transfer any riglzts or obligatioils under tivs Cozltract witllout prior written approval of City.O1�ly tllose
pexsons whose 1lames are ulcluded in Exliibit A may�erform t11e Services.
10. Publicity and Signs.Any publicity generated by Coxltractor related to tivs coiltract or
tlle Services duruzg filie Colztiact Tiine and for one year thereafter inust reference City contributions.
The words "City of Cupertino" shall be displayed ix1 aIl pieces of publicity, includuzg flyers, press
releases, posl-ers, brochures, pubJzc service a��nounceinents, interviews ayld newspaper articles. No
signs may be posted,exhibited or di�plaped on or about City propertq,except sigi�age required by law
or ulider this Agreement without prior writtezz approval froin City.
11. Indemnification.To the fixlTest extent allowed by law a�1d except for losses caused by
the sole i�egligence or willful iniscoxlduct of City personnel, Coniractor agrees to i�lden�ulify, defend, �
and 11o1d harinless the City, its City Cotulcil, boards and coi�nanissions, officers, officials, eznployees,
agents, servanfs, volwzteers �zd Coi�tractors (collectively, "I�idea.xuvtees"), througll legal counsel
acceptable to City, fiom and agavlsf �zy liability for da7nages, clauns, actions, causes of action,
dezn�lds,cllarges,losses,costs and expeilses(u2clnd'u�g attorney fees,legal costs and expexlses xelated
to litigatiorl,arbitrations,admirvstrative and regulatory�roceedings), of every nature,arisi�lg out of ox
v1 anST way relafed to Contracfior's or Co1li�actor's agents perforinatice of t11is contract or�ze Services.
This vlcludes but is 11ot limited to Liability resulti�.zg u1 personal uljury, deatl�, property damage, or
economic Iosses. Coniractor anust pay aily cosfis City may ulcur i�z enforci�lg tl-us provisioil and must
accept a tender of defellse u�o11 receiving notice fioin City.Coi-�iiactor's payments may be ded.ucted or
offset to cover arly moiley the City lost due to a clairn or counfierclaim aris�2g out of tl-iis Conhact.
12. Insurance.Co1z�i actor shall comply wit11 the insurarlce requireinents in Exhibit S. City
_ _ _ _ _ _ _will_not_execufe the Agreeinent until it has received and approved satisfactoiy certificates of i��sural�ce
_ ____
- - ---
�uzd endorsenlents evideizculg the type, amount, aizd dates o�coverage. Alternatively, City�1 its so e
discretion lnay purcllase i��surailce and deduct tlle cosks frorn�aymellts to Con�iactor,or terminate 11ze
contract.
Recrecttion Se���ices 14greeme�at/Rev.3-14-20X 8
Page 2 0£12
13. Coxnpliartce with Laws and Otl�er City Requiren�eiits.
Requirentertts foar a11 Coz�tracts. Tl�is con�iact is suUject fio Iocal, state and federal Iaws and
reguIations�iollibitvzg discii�ir�ation,�Zcludi�lg Title VII of the Civil Rigllts Act of 1964,t1�e Califol�nia
Faii Employlnellt Practices Act,fille Anzerica�ls witll Disabrlitzes Act o�1990,ayld otlzer latvs that�ertauz
to £air ernployinerlt and a�zii-discz�irnulation prlctices. Contractor must comply wiL-h Tabor .laws
pertaul�lg to pxevailv.lg wages, warkulg hours, overf�:rne, payroll xecords, 1nd ofller reqttireineazts
i�nposed by t11e Departtz�.ent oE I�ldustrial Relati.ons.If Contractor does not have e�nployees,it lnust sign
t11e Affidavit of No Einployees, aftacTled as Exhibit G Consultazzt is responsible for verifying
employinent eligibrlify of eanployees �utsua7li to tlie Iminigration Reforin and Control Act of 1986.
Contractor n�ust comply wit1�cor�Iict of�zlterest Iaws a�zd regulations applicable to tl�is Agreement at1c1
avoid conflicts of ulterest. Contractor znay be required to file a coa-�flicf of interesf forin for exlgagulg i�1
gover�vnental decxsiolzs or servvlg iu1 a staff capacity,a11d is hereby advzsed to xeview t11e requireinenfs
of C�lifornia Political Reforin Act �Zd the Califorxlia Code of Regiila�ions. Services rnay otzly be
performed by persons who are not eznployed by City and wlZo do ito�have a contractual ielatiolzship
wi�l1 Ciiy oiher tlla�z tl-iis contract.Contractor agrees to abide by Cify�olicies and admulistrative rules
prahibitiuig gifts fo City officials a11d erxlpIoyees.
Additianal Requirements for Sexvices Provided to Minors: Conlracl-or and its exn�loyees
wlZo provide services utzder this Agreeznent nlust co�nply wil-h fillese add.ifionaJ reqturemellts,
A. Undergo fingerprulting a7zd. a criininal background checic a11c7 veri{y a11 ernp�oyees
�roviding services tulde�t11is contract 12ave inef t�1is requireinent.
B. Complete a Tuberculosrs screenu�g�esf as required by law and as set£orth u1 Exhibi.t D.
C. Comply with the Mai2datory Reportulg wlder CaliSorrria Pena1 Code 17.164-11174.3 and wiFh
�1e protocols, reporting, arzd t�aini�lg required under California Hea1�11 and Safety Code
Seciiol7 124235,AB2007, ancl otIler laws pertainirzg to concussioiz evaluation,re7a�oval froln
play, ar1c� return to pTay protocols. (Refer to Center for Disease Confrol & Prevelztion,
l��s://ww�v.cdc.gov/headsu� index X1tm1),
D. Subrnit required folmms and aclazowledgments ulcluded u1 Exhibif D, arzd ezzsure its eac11
�articipant is provided�vi�Iz a co7lcussion u-t#ormation sl�eet,sigz-is and returns t11e fonns to
tl�e City as requ�ired by Healtll and Safety Code Secfion 124235.
Requzre coaches alid adin�listrators to successfully colnplete i:11e concussion and head�1Jury
education at least once eitller on]v1e or u1 persol�, before supervising a participant.
Contzactor sha11 offer tx�inulg, educational lnateria.Ts, or i�ot11 io eacli Co�ltractor
admitlist�ator o11 a yearly basis. (Trai�litlg xesources are available at the Center for Disease
Control&Prevezltiozz(1i7zlc cited above).
E. If providing i�zstructiozz, Coiltiactor inust aclalowledge and coinply wi�lz al1 requixeineilts
set forth u�1he Recreatiort&Coininunity Services�izstruclor Manual.
C�ecic one(if a��lica�le):
❑ Tlzis coiltxact arec�uues services for clzilcl�en.
Rec�°ec�tzon Servaces Agreement/Rev. 3-14-2Q18
Page 3 of 12
� This contract cw�rea�tly does xlot requue services for childreiz. If uz tlle tuture, services
for children are requued,tlze contract will require a`written ameYzdlnen t'to i�lclude tlle
appro�riate uzsurazlce coverages as required i�1`Exhibit B-Ir.zsuraizce Requireinents for
Recreatioil Coi�fracts', proof of fitlger pri�lting aild additional requueineizts iuzder
I'aragraph 13. The con�xact a�nenclinent wi11 also requixe fi11e approval of the Director of
Recreation and Coinm�.uziey Services and Citq Attorzley.
14. Coordination of Services. The Patties designafe tl�e followuzg persoi�.s as Services '
Cooxduzators with the responsibility fio oversee the delivery of Sexvices u1 accordance with flze terms of
this AgreexneXlt.Coizfiactor's desigxzatiorl and�iy substitution are subject to City aYproval,
For City: For Coniractor:
Naine:Karen Levy Naine:Juaxz He
Posifizon:Recreation Coordi�zator I'osition:Da�zce Tilstructor
Contact:lcareill@cu�erti�io.or�;408-777-3123 Coi�tact: '
15. Abandonment.City may abandoiz or postporle the Activity or Program and will notify
Contractor as sooii as possible. Contractor will be paid fo�satisfactory Services reildered tiv�ough the
date of abandoiunent upon subYnissiol�of final invoices app�oved bq City.
16. Termination. City may l-erininate fi11is contract for cause or witllout cause at any tune
and will notify Contractor ae soon as possible.Contractor will be�aid for safisfactory services relldered
tl-uough the dafie of tertni�z�tion upon submission of fu1al invoices a�proved by City,
17. Gaverning Law,Venue and Dispute Resolution.T'his cont�act is governed by tlie Iaws
of the State of Califol�lia. Any 1egal actions or proceed'ulgs filed against City in connectioxz with thzs
contract must comply wii�z ihe governinent cXaiins fil'vzg requixeinerlts and xnusf be filed witll the
Superior Court for the County of Santa Claxa, Siate of Califoriv.a. At City's request, Corliractor is
required to conti�iue to provide Services �endr�lg resolutiolz of arly dispute. If the Parties elect
arbitration, the arbitrator's award inust be su�ported by Iaw and suUstanti�I evidence atld ulclude
detailed writterl fi�zdings of 11w aild fact.
18. Attorney Fees. If City is required to pursue]itigation,arbitration or otller adiniivstrative
or regulatorq proceedulg to enforce its rigllts or the terrns of tllis Agreement,the prevail'u1g party witll
be exltitled to reasonable attorney fees a��d costs.T11is Section survives t11is Agreement.
19. Third ParEy Beneficiaries.There are xzo tllird parfy beizefici�ries iulder this Coxltracf.
- _ _ - - - -
2�. Waiver:Nei�ller accept�lce ofServa:ces 11or payinent tllexeof constitutes_a_waiver o_ a�1y__ _ _ ___
contract provision. City waiver of a breach sh�ll not constitute waiver of anotller terin, �rovision,
covenant or coi�clition,or a subsequent breacll,whe�Izer of the sa�ne or a different character.
21. Entire Agreernent.This Agxee�nerlt and al1 referexzced Exhibits are hereby atEached and
i�lcor�orated i�1to the Agxeeinent bq tl-iis reference and represezlt the full and complete understandi��g
as to tllose matters contained ilereuz,alzd supersede a��y other colltract ox ulldeistandi�lg,either oral or
Recr�eation Services Ag�^eenient/.Rev. 3-14-2018
Page4of12
IN WITNESS WHEREOF,t11e partzes have caused this con�iact to be executed.
CONTRACTOR CTTY pF CUPERTINO
J'��r��I� A M�.ulicipal Corj�o��ation
�
By 'I . ���.�-�... �
Name_��tA�+rl�P F��__ Naine��' ,%�J ��7c:�
Title�t;�ro _`1.a�"��tc� TitIe�', ��,ii'�C.�`�Y"�
Date ��IG�(� .� ?� .�,� Uate ����'-�'
Tax I.D.No.;refer to W-9 on fzle
APPROVED AS TO FORM: ATTEST:
Y ,
d� �,��� � ��� �
RANDOLPH STEVENS N HOM GRACE SCHMIDT
Cupertixlo City Attor�ley City Clerl< ��'"���'
Coa7t�•actlEncumberedAmount:$12,000
Accoulzt No.;580-63-620
Rec��eation SeT^vices Ag�^eement/Rev. 3-14-2018
Page 6 of 12
�=ritteYl,betweeil the Parties.Tl.zis Agreemexlt may not be inodified or anzended except in writing signec7
by both Parties.If there is a�1y i��consistency beiween the inauz cont�acf and any aEtacl�unents or e�cYubits
Ehereto,tlle�nain coa�t�act shall prevail.
22. Inserted Provisians.Each provision or clause required by law'or tlzis contxact is deemed
to be i�zcluded aild will be inferred lzereul. Either party m1y request �1 ainei�dment to cure �zy
inistaken insertion or omission of a requued provision.
23. Headings.Tl1e Jleadings are.for conveivence only�1d are not a part of the conhact or
i�-�tended to affect,Iilnit or ainplify the terms or�rovisi.ozls of tivs Agreement.
24. Sevexability/Partial Invalidity.If ai�y conhact terbn or provisiorl,or tlleir application to
a particular situation, is found by f11e court fo be void, �Zvalid, illegal or tu�enforceable,sttch term or
provision s11all re�airz i�z force and effect to tlle extent allowed by sucll ruling.All odlex colltract terms
and provisions and their application to specific situations will reinai�z u1 fuTl force axld effect.
25. Survival.All provisions wl�icll by tlleir nature inust continue after tlle Agreeinent ends,
includ'u�g without Iimitation I�1de�ru7ification,Insurance,Ownersl2i�of Matei�ials,Records, Governing
Law aild Atto1�-�ey Fees,will survive the expuatioxl or terrnulation of fhis Agreei�nent.�
26. Notices.All notices and'uzstrtunents pertaini�ag to material�rovisioazs of�12is coniract or
significalzt dis�uEes wlvcll are required by l�w or wlder this contract to be ui wriEing must be seilt to
the persons Iisted below. The notices will be deemed effective oi1 the date of persoi�al delivery or t11e
date confirined by a reputable overzught delivery sexvice,on t11e fifdl calendar day after deposit u1 t11e
Ui�ted Sfates Mail, postage prepaid, registered or certified, or the next busuless day followittg
elecironic subznission.
To City of Cu�ertino: To Contxactor:
Office of�11e City NIanager
10300 Torre Ave.,Cupezti�lo CA 95014 Cupertulo,CA 950"14
cc:Representative/Coord'ulator: cc:Represelzfative/Coordiuzator:
Karen Levy Juv1 He
Cmail: lcarenlC�cu�ertino.org Email:
27. Validity of Contract.TI1is contract is valid a�zd ertforceable only if it compLies with fl1e
provisions of Cupertino Municipal Code Clzapters 3.22 and 3.23, is signed by the City Manager or
autllorized desig�lee, and is approved for form by the City Attorney's Office,
- - - - - - - - - -
28. Execution. T`lie persorl execuEillg t11is-coritract o111�ehalf of Coillx�etor-re�rese�lts-an - - --- - -
warrants that Contractor l�as fu]I rigllt,power, aild authority to execute thzs cozlfra.ct and to carry out
all actions aild services required. This coiltrlct colzstitutes a legally bindulg obligation of Coxzfractor,
and may be executed i�1 eounEer�arts, eacll one ot whicll is deemed an origi�lal and a1I of whidl, talcen
together, constitute a sutgle bi�lding ulst�ument.
Recreatio�T Services Agreenient/Rev.3-14-2018
Page 5 of 12
EXHIBIT A
SCOl'�OP WORK,PERPORMANCE AND PAYMENT SCHEDUL�u
The CQNTRACTOR will�rovzde DANC�INSTRUCTION zn,but not lianited to,the following:
CC)NT�?MPORARY&CHINESE DANC�
Location ar�d Time of CONTRACTOR Seivzces:
Refer to tl�e Recreation Sclledule dated SUM.MER 2018—SPRING 2020£or agx•eed u�oi1 dates,tiz�les, and
class locations.The City,at its sole discretion,may clzange the agreed terms.
Cornpensation for CONTRACTOR Services:
Contxactor shall be coznpensated for sexvices pexforined pursuant to this Agreement.Corn�ensation shaIl '
consist of the followiilg:65%of residezzt fees plus 65%of drop-in fees,The Lofial coi���ensafioll to the Cont�actor
shaIl not exceed$12,000. (FY 17/18=$1000;FY 18/19=$5500;FY 1g/20�$5500).
�Iigible�'lrficipant Minimttrn and Maximurns for CONTRACTOR Services:
Minimuin: 1 Q
Maximunl: 2Q
I£less tharl the requixed ininilnuin nuinber o f participants enroIl ui alzd�ay for a particular class as identified ii2
the scheduIe before the class is scheduled to start,tlle City may caYlcel the�articulax class aild/or terininate thzs
Agreeinent witllaut additioilal zzotice or paymezlt to Contractor.
List of a1Z Contracta�r EmpZoyees working for the City of Cttpertino(if no ExnpIoyees,identify"seIf"):
self
Performance of CONTRACTOR Services:
7�z t11e case Contractor unilaterally cancels perforz�lailee of a class,calnp,activity or service without City
approval,City reserves Uze rigllt to iznizZediately atld�vithout notice cancel the remainder of pxograixls/services
offered aild or performed by Contractor.
The Contractor sl�all follow alI gtzidelines pertaizlizzg to regisiratioil procedures as lisfed in t11e quarterly
recreation schedule,Partici�ants lilay i�ot take part in t11e program unless t11ey are listed oi1 tl�e class roster or
can s11ow proof of eiuollnlent.All participants azld volunteers need to cornplefie t11e City's W�iver of Liability
form prior to ta.1<ing part in the prograixl,If applicable,contractors w110 are respoxzsible for supervising ininols
lnust reinain witlt the class w1ti1 a parent of le.gal guardiax111as arrived a71d all mulors are xeleased to thezn,
In tlle evenfi of an il�jury occurxing to a pariici�ant, lhe Contractox will ilotify the City witllin 111ouz�and coznplete
an Iilcident Re�ort in the forr�l a��roved by t11e City, Tl1e T�zcident Report nlust be subrnitted to tlze Ci.ty wiihiil
24 Ilours of tlie iz�jury occui•rizlg.
Recreatio��Se�ryices�4gt•ee»ie��t/Rev. 3-14-20I8
� Page7of12
ExxzBz�r s
INSURANCE AEQUIREM�NTS
Contractor shall procure and maintain fox the duiatioli of the contract uzsurailce against claims for injnries
to persons ox daulages fio propexty wl�ich may arise froin or in coi�zlection wiEh the perforznance of the
- work hereundex a�1d the zesults of that worlc by the ConEractor,lv.s agents,repxesentatives,employees or
subcontractors.
MINIMUM SCOPE AND LTMTT OF INSURANCE
Covexage shall be at deast as���oad as:
1. Commercial General Liabilify(CGL):InsLtxa�lce Sexvices Office Form CG 00 01 coveriz�g CGL on an
"occurrence"basis,including�roperty dainage,bodily injuxy and personal&advertising injuiy with ,
lunits no less than$2,000,000 per occurrence.If a gezleral aggregate li�nit applies,eithex flle general
aggregate lixnit shall a�ply sepaxately to this projectJJocation(ISO CG 25 03 or 25 04)oi the genexal
aggxegate lia�it shall be twice the required occurrence li�nit,
2.Sexual Abuse/Molestation insurance ox the equivalent are required for cont'racts involving cluldren in
after school activities,recLeational j�xogxa�ls,athletics,siudies,transportation of students.Covers pofenfial
cla'vns of��use or cluJd mo]estation.Sexual Abuse/Molestatioil coverage inustbe induded undei General
Liabality ox obtauzed in separafe policies in an�nounE of noi less than$1,000,000�er occuxrence
($2,0OO,OQO aggregate) and$3,000,000 excess/umbrella coverage.
3.A�.tomobi7e Liability:If applicable,a declaration page showing current pioof of au.tomobile ulsur�nce,
displaying coverage arnounts afi or above the CaJifornia statutoxy r�nin.i-�.nuins,is required.
4.Worlcers'Cornpensation insurance as requiied by the State of California,wit11 Statutory Lisnifis,and �
E�nployer's Liability Insurance with lurut of no less than$1,000,000�ex accident for bodily injuxy or
disease. (Note-required anly it Contxactoi has ein�loyees).
If the contractor main�ains broader coverage and/or l�igher liuuts t11an the iniivinums shown above,the
City iequires and sl�all be entitl.ed to fltebroadex covexage and/or 1ligher limits maintained by tlze
contractor,Any available insurance pioceeds in excess of tlle s�ecified m'v1'vnwn l'vnits of ulsurarlce and
coverage shall be available to the City.
Sel f-btsured Reteaitions
5elf-insured refeniions must be declared fo and a�proved bq the City.The City inay x'equi�'e the Contzactox
to pxovide�?roof of ability to pay losses a�1d related investigations, cla'v.n acl�ninistra�on, and defense
expenses within tile retealtioil.The policy la�lguage shall provide,or Ue endorsed to provide,that the self-
_ __insure_d_xetenfion inay be_satisfied by either the ncuned insured ox City.
Other Insuxarice Provisions
The generalliaUility�olicy is to contain,oi be endoxsed to contairl,the following provisiolls:
Recreatio�z Selvices Agree»�ent/Rev. 3-14-2018
Page 8 of 12
1.The Entity,its afficers,afficials,emplayees,agents,anc�volunteers are to be covered as additrorial
insurec�s wifih respect to liabiliiy arising out of woxk or operations�erformed by or on behalf of t11e
I�Zstructor including materials,p�fs or eqttipmellt furnished in colmection witlz such woxk or operations.
2.For any clauns reIated to this contracf,the Tnstru�tor's i.nsura�nce cove�age shall be primary ia.lsttrance
coverage at least as broad as ISO CG 20 01 0413 as respects tlie Ezitity,ifis officers,officials,ernployees,
agents,and valunteers.
3,The I�1sur�ulce Colnpany agrees to waive all rights of snbrogation against the Eniity,its elected or
appointed o£�cers,officials,ageilts,and elnployees for losses paid utider tl�e terms of�ny policy which
arise fioln worl<perforined by the Insfiructor fox the Entity.This provision also applies to the Instx�uctor's
Worlcers'Com�ensation policy,
4.Each insurance policy required above shall provide thaf coverage sliall not Ue canceled,except with
notice ta t11e Enfity,
Acceptability of Ivcsurel�s
Insurance is to be placed with insurers with a current A.M,Best's rating of no Iess than A:VII,uzlless
o[herwise acce�table to t11e Ei�tity.
Verification of Cove1^age
Instn.ictor shalX furnish the Bntity with original certifi.cates and amendatory endorsements effectiilg
coverage required by fltis clause.AlI certificates and endorsements are to be received and ap�roved by the
Entity before work coixunences.The Entity reserves t11e right to require coxnplete,cextified copies of a11
reqrxired itisurailce policaes,includiYlg endorsemerlts affecting the coverage reqr,iir.ed by tllese
specifications,at any time,We strongly recommenc�obtaining a co�y of the policy decl�rations and
endorsernent page(inal<e this a r�quirexnent ir1 Srour Confract)to facilitate verification of coverages atld
spot any uridesilable policy limitations or exclusions.
Hot�ieowne7^'s I��sus^a�ice
In soine cases the Instructor's homeowx�er's liaUility insurance may provide coverage suff7.cienfi fio ineet
tllese requirements.I��stiuctor sliould provide ihese reqtiirernerits to his or her agent to confirm arid
provide verification to the Enfity.
S�aeciccl Evea�ts Coves�age fot^I�zst��zccta�Rs
Special events coverage is available for an additional fee to provide 111e liability u�sur�nce required by tliis
agreement.Tnstructor can ol�tain�dditional infornlltion and cost fionl the Erltity,
Special ot^Low Rislc Activities
Entity reserves fl1e right to lnodify Ihese req7xirelxients,includang luniLs,based ori i11e nahxre o£tite risl<,
piior experience,insurer,coverage,or otliex special circumstances.Tl�e�ntity resexves the right lo xnoclify
or waive insurance requueinen:L-s for cerfa.in low rislc recreational ac�ivities.
Recreation Se�vices flgree»aent/Rev. 3-X4-2018
Page 9 of 12
�xxz$IT c
AFFIDAVIT O�NO EMPLOYEES
State of Califor��.ia
County of Sar�.ta Cla��a
City of Cuperfino
I, the undersigned, declare as follows:
I am an independent dance instructor.I wish to eizfier into a services contract vsith tlle City of
Cupertino. I am fully aware af the provisions of section 3700 of the California Labor Code,
whicll requires every einployer to provide Workers' Compensatioil cove�age for employees
in accordance witll�11e provisions o£that Code. I am also aware that I nlust provide proof of
worlcers' compezlsation insurance to the City of Cupertino fo�any aild alI enlployees I inay
have,pursuailt to Section 12 of the City of Cupertino's coiltract.
I hereby certify thafi I do not have any einployees nor will I have any ernployees wo�l<ing for
ine or my busilless during tlle term of aizy service corztract with the City of Cupertino. T am
not required to have Worl<ers' Com�eilsation insura�lce.
I declaxe unde�penalty of perjury under the laws of the State of California that the foiegoing
is true a11d correct. .
�xecuted or1 this ��1 day of �0-t~' 2018, at Cut�ertino, California.
�i�-�9-� �"��
PRINT NAM�C
����+r� �
SIGNATURE
Recreatio�z Services fig�^eemen.t/Rev. 3-14-2018
Page 10 of 12
EXHIBZT D '
Cont�actor's Mandaiec�.Repa�ter Declarati.vn
The unc(ersigned does hereby cextify that:
1. I am,a representative of JUAN H�;that I azn familiar with tlle facts 1lerein and am
authorized a11d qualified to execute tl�.is decla.ratiorl.
2. T c�eclare t111t JUAN HE has complied with fingerprixzting and criznilzal background
investigation requiren1e11ts with respect to aIl Coi2fiactor's employees who rnay have
contact with rni�lors in the course of providing servi.ces pursuaz�t to the Agieement; azzd
t11e CaIifornia Departn�ent af Jusfiice has deterri�uled t11af�Zone of those enlployees has
been coilvicfed o£a felo�zy, �s t��at terz��is defined ir1 California Pei�al Code Section
11105.3.
3. I declare that each coacl�.and adminisfrator shall be required to successfully colnplete
concussiozl and head injury education at Ieast once, either oylline or in�erson,Uefore
supez•visillg a participant;as required by California Hea1�h and Safety Code Section
124235, ef seq.
4. 011 a yearly basis, all p.articip�nts sha11 be required to sign ax-�d returzl a concussion and
I1ead ulj�iy iz-i.forrnation sheef in compliance with Califorizia Health and Safety Code
Sectioi1124235, whzch may be in tlie form aftaclled as D-1.
5. That a coznplefie and accurate iist of Contracfor's einployees, who may conle 'vt co�ta.ct
wit�l milzors during t1�e course and scope of the Ag��eelnent, are included below.
6. All of tl,e below nlentioned ernployees have�ested.X�egafive for TB, or X-ra.y results fox
TB, and have current docum.entltion on fiYe with Contzactor.
7. AIl of the below.m.ei7tiorled employees ha�re teceived trauling and understand theit
responsibilities undex the Mandated Reporter Xaws of fhis state �nd are williilg az�d a61e ta
coinpl�r.
List of all Coiitractar Ernployees working for the City(i.f no E1xtployees,identi.fy"selfrr�.
self
8. Tl�e Coni.7�ctor wi11 notify the City of Cupertillo in�vriting of any new en�ployees and
will be added to the above list�rioz to beginn.ulg w�orI<at the City of Cupertirlo.
Recreation ServrcesAgr^ee�nent/Rev. 3-14-2018
Page 11 of 12
I declare under penalty of perjury that the foregoing is true and corxect.
JUAN HE
��—'�,�� -
By: JUAN HE
Title: DANCE INSTRUCTOR �
Date: C�l�� %��/�`- �( �
Recreation Ser^vices rlgreera2ent/Rev. 3-14-2018
Page 12 of 12
EV.ANSTON INSUIZANCE COM�'ANY
C�RTIFICATE NO.: 6365-70516566511448
CERTII+ICAT�OF'1NSURANCE
SPECIAL�VENT LIABTLITY 1'ROGTLAM
PRODUCBR PUBLIC ENTIT'Y(AI}DITIONAL INSURED)
Alliaut Iiisurance Services,Izzc,in conjunctioit witli City of Cupertino
Apex Insurauce Services
P.O.Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAI1�D TNSURED(EVENT HOLD�R): EVBNT INFORMATION:
Juan He Z'ypE; Dance(Various)
DATE(S); 03/19/2018-12/31/2018
Cupertino, CA 95014 LOCATION: QuinlanCanmunttyCanter,1o1u5North5lallingrzooa,Cuperilno,CAe5o14
*Liquor LiaUility Yes� No��•
"`*Li uor Liability after 12 am ends bePore 2 am ❑
Tlais is to cerCify that tI�e insurance policy listed beIow I�as been issued to the above insured t�amed(event holder)for the polioy
period indicated. The insurance clescribed l�erein is subject to a11 the tea•ms,exclusions and conditiovs af such policy(ies)unless
amended as descriUecl in Special Conditious.
1NSURANCE CARILT�R:Evanston Insurance Company
MAST�R POLTCY NUMBER: SEP41026
- MASTERPOLICY AATES; EFFECTIVC: January o1,2o9a �XPIRATION: January 01,2019
COAIIvI�RCIAL GENLRAL LIABILITY GeneraI OCCURRBNC&FOIZM DEDUCTIBLE: NONE
Aggregnte Liauit $2,000,00�
Products&Completed Operations 1,000,000 SPECIAL CONDITiONS:
Peisonal&Adveitising Iujmy 1,000,000 The following endorsements attached to
Each Occun�ence L'uuit 1,000,000 the Master Policy do not apply to this
Dflmlge To Premises Kented To You.(Any One Premises) 100,000 Certiflcate Of Insarat'ace;
Medical Pa}nnents(Auy One Person) 5>000 ML�GI,1643
LiquorLiability (If,purcl�ased) 1,000,000
Optional Linnils Purchased
❑ $1,00a,000/$3,400,000
❑■ $2,000,000/$2,�00,000
Px•operty Damage(If purchased)
No Proper�y Damage Coverage
The Inuits of iusmunce apply separ�tely to each event insured by this yaolicy as if a separate polioy ofinsw�ance has been issued for that event.
OTIiER ADDITTONAL INSUREDS
City of Cupertino, Ifis City Cauncil, Boards and
Commissions, Officers, Officials, Ernployees,
Agenfis, Servants, Valunteers and Consultanfs
CANCELLATION: Should the above described k�olicy be cancelled Uefore ilxe expu�aiion date thei�eof,notice will Ue delivered in accordauce with 8ie policy
provisions.
��
w't'"v�y _�`^�t`��..,�-.x.�.�.
��-
AUTHORIZED REPRES�N'CA"CTV�:
llAT'�.1S SiJ�D: 03/19/2018
POLICY NUMBER; SEP41Q26 COMMERCIAL GENERAL l.IABILfTY
CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
�►DDI1'IONAL �NSURED - DESIGNATED
PERSC}IV OR ORC�ANIZATlON
This endorsement modifies insurance provided under the foilowing:
COMMERCIAL GENERAL LIA8ILITY COVERAGE PART
SCHEDULE
Name Of Additiona!Insured Person(s) Or Organixation{s):
City of Cuper�ino, Its Cify Council,8oards and Commissions, Of�cers,
Officials, Emptoyees,Agenfs,Servants,Volunteers and Consultants
For Certificate No.: 636570516566511448
Informafion 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 fhe insurance afforded to these
include as an additionai insured the person(s) or additional insureds, the following is added to
organization(s) shown in the Schedule, but only Sectian lil-Limits Of Insurance:
with respect to liabilify for"boc[ily injury", "property If coverage provided to the additiona! 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 ,,�r��l pay on behalf of#he additional insured is fhe
omissions flr the acts or omissions of those acting amount of insurance:
on your behalf:
1. In the performance of your ongoing operations; 1. Required by the contracfi or agreement; or
or 2. Available under the app(icable Limits of
2. !n 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
Declarations.
- - - - - insur_ed�nfY-app-lies ta_the.exfent permitted by-- - --------- -___ - -------- ---- ----- --- - ------------ - - -- --- - --
law;and
2. If coverage provided to tl�e additional insured is
required by a contract or agreement, the
insurance afforded to such additianal insured
will not be broader fhan that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 26 04 13 OO Insurance Services Office, Inc., 2012 Page 9 of 1
���
FARMERS
Auto Insurance Declaration Page ��S�,�AN��
PolicyNumber: 17607-74-36 Premiums/Fees
. .. . . . . . . . . .. . . . . . .. . . . .. . . . . .. . . . . . . . . .. . . . .. ... . . . .
Effective: 4/25/201 8 1 2:01 AM Policy Premium $364.50
Expiration: 10/25/201812:01 AM
Named Insured(s):Juan He Fees(*also see Information on Additional $0.88
Fees below)
Cupertino,CA 95014-2013 �^~ po6icy Prerrsfum and Fees $365.38
e-mail
Address(es):
This is not a bill.
Underwritten By: Farmers Insurance Exchange Your bill with the amount due will be mailed separately.
6301 Owensmouth Ave.
Woodland Hills,CA91367
Household Drivers
All persons who drive or will occasionally be driving any ofthe cars on the policy should be listed below.Ifanyone is missing or needs to
be added,such as a newly licensed driver,you should contact your agent or the company to add that person before they begin to drive
any of the cars covered on the pol icy.
Name DriverStatus Name DrlverStatus
_......,�,.._._.___�_ .m..w.._�.�_,_._�__.._.�.�_..���_.�..�_....w.
� _.� _�.,�.
Excluded
Vehicle Information
Veh.# Year/Make/Model/VIN Coverage Deductible Limit
�___��___..__..�._m _m_._�_w_.__�.__�.____.. �..w_.... w�__._ ._,�___ ._...._�._��.M...�_�....�_�._._���._.��_._.�__�...�.�._�.w_�...
1
Collision: $1,000
Additional Equipment: $1,000
Coverage Information
Limits Premiums byVehicle
.._...._ ......_.._ _......... .. ....... ... _.....
__..
overage (applicable to all vehicles) Vehicle 1
........... _ _.._......
Bodily Injury Liability $15,000 each person $214.20
$30,000 each accident
_ __. ... ...__ ..__ _... .._. ..... _.... . _.. .. ..._... _ .._._ _..._._ . _...._...
Property Damage Liability $10,000 each accident Included
--.._ .._.__._,. ..__ _ ___ - _�._.. _.._... .-- - __- _ --- � -._._._ _—... - - _�. _ _� --� ----- _-
Permissive User Limitof Full(5ee Permissive User Included
Liability** Limit of Liability in your
pnl icy)
_ . ..._. .. ...... ..... _......... . . _ ..._...... _........ _
Medical Coverage Not Covered
UninsuredMotorist Bodily......................_................ ........... ...................... ..........................................._.............................................................. ..Not Covered
Injury
--- - � �� - _� ----- _ � �- - ... -�-- --�-�-- - _ ......... --�-�-_.._.. ---� --- -� -------__...� ---� �--.._._...--- -
Comprehensive Not Covered
_. ... _.... .........
Collision
$150.30
farmers.com Policy No. 17607-74-36 Questions? Manage your account:
Call youragent Lydia L Chang at(626) Go to www.farmers.com to access
205-8933 oremail youraccountanytime!
Ili@farmersagent.com
56-6176 1stEdition 5-17 2/28/2018
Page 1 of 3
Declaration Page(continued)
Limits Premiums by Vehicle
_
Coverage (o licable to all vehicles Vehicle 1
___
_.... Pp . __ _._...... .. . . )._. __. ...... _. . _..._... _ ... _...
Additional Equipment Inclu e
_.__.._ __.--_._-__.___.____.._.__._...___.__..---._._...___....__---.__.._.___.._...___.______..----.__.__---__ ..---.__.._..__..____---------_...._______. _.....
Uninsured Motorist Property Not Covered
Damage With Collision
_ .... ..._.. _._ ......... .. . ....... . ............ ..._ _........_. _..._.... .... . __
Towing and Road Service NotCovered
Total Premium PerVehicle $364.50
�""" Policy Premium $364.50
Fee Detail
Vehicle 1 Total
_ .._�.�_,��..�.� �W_�_.__ _�_.�.._..��_. .._.� _......�e____..,.�W_.�_ �___��_._�._....� �__....�.__._�___��...�.
Anti-Fraud Fee $0.88 $0.88
�!'""" Fees ��'$8
� Policy Premium and Pees $365.38
Discounts
Discount Type Applies to Vehicle(s) Discount Type Applies to Vehicle(s)
x..._.�W_,_�.___�..�.�..__�_ �� r r.... �.v._�.��._.�� _.W._.._..�..._ _..�,_..�v__.���._.� �__� ..��w_.�___..�.�...
Anti-Lock Brakes 1 Good Driver 1
_................... . ...... . .......... ..._ ..,,.... .,..._..._...,,........_. ....... ..._......................_.........�,..........._....... �.�.�.._.....�.........�......._........._
Group-Farmers Agt 1 Persistency �
........................�._._......��__.....�......_...�.....___........_..��_...:«........_.__...,........__.....
Safe Driver �
Rating Information
Detaiis Vehicle 1
_._
_ _....
_.._ 95014
Garaging Zip
_.. ......... . ......._ __. .__.... _ _. ...__ _. ..._... __.....__ _ _ ._
___...... .
CurrentAnnual Mileage 5,00
_ _......__ ___ ___._ ..____. __.__.__ _._..__._... --__._ ___.__ __----. _ _._ ...___.__---_.__
_.
Previous Annual Mileage 5,000
_._..__ . _ .__._ ._._... . _...._.._ _...._ ._. ......... .__... __.. .__.._._. _ .._.. ._._ _.._. .... ....__ ..._ ...
Vehicle Usage Other Use
_._._ ._. .._.. _ . ..._____. .._... .__. ..._ _ ....._.._ ......... __.._.._ ...._ _.. ..._....__
Years of Driving Experience 19-23
Policy and Endorsements
This section lists the policy form number and any applicable endorsements that make up your insurance contract.Any endorsements
- - - -
- - - - -
that you have purchased to extend coverage on your policy are also listed in the coverages section ofthis ec arations- ocumen: - -- - - -
56-56841st ed.;CA1251st ed.;J70341st ed.;25-8531 10-12
Other Information
• **YOUR POLICY INCLUDES THE FULL PERMISSNE USER LIMIT OF LIABILITY.PLEASE SEE PERMISSIVE USER LIM►T OF LIABILITY fN
YOUR POL►CY FOR FURTHER►NFORMAT►ON.
farmers.com PolicyNo. 17607-74-36 Questions? Manage youraccount:
CallyouragentLydiaLChangat(626) Gotowww.farmers.com to access
205-8933 oremail youraccountanytime!
Ili@farmersagent.com
56-6176 1st Edition 5-17 Page 2 of 3
Declaration Page(continued)
• You may be eligible for a different rate but with difFerent coverage from Farmers Specialty Insurance Company.Please contact your
Farmers°agent to discuss your options.
• TheAttorney-In-Fact(AIF)ormanagementfeeforyourrenewedpolicywillneverexceed20%ofthepolicy'spremiumsandwillbe
paid out ofthe premiums.You maywish to considerthis information in deciding whetherto accept ordeclinethis offerto renew
your policy.
• You have the right to designate an additional third party to receive any notice ofcancellation for nonpayment ofyour premium for
this poficy. Please contact your Farmers°agent ifyou would like to add,change,or remove a designee.
• Farmers Friendly Reviews are a great way to make sure you are receiving all the discounts for which you qualify,and identify any
potential gaps in coverage.Contact your agentto learn more about the policy discounts,coverage options,and other product
ofFerings that may be available to you.
*Information onAdditional Fees
The"Fees"stated in the"Premium/Fees"section on the front apply on a per-policy,not an account basis.The following additional fees
also apply:
1. Service Charge per installment(In consideration ofour 2. Late Fee:$10.00(applied peraccount)
agreement to allow you to pay in instaliments): 3. Returned Payment Charge:$25.00(applied per check,
- For Recurring Electronic Funds Transfer(EFT) and fully electronic transaction,or other remittance which is not
enrolled online billing(paperless): $0.00(applied per honored byyourfinancial institution forany reason including
account) but not limited to insufficient funds or a closed account)
- Forother Recurring EFT plans:$2.00(applied per account)
- For all other payment plans:$5.00(applied per account) 4. Reinstatement Fee:$18.40(applied pervehicle,20%
discount will apply for Good Drivers)
Ifthis account is for more than one policy,changes in these fees are
not effective until the revised fee information is provided for each One or more ofthe fees or charges described above may be �
policy. deemed a part of premium under applicable state law.
Countersignature
�`��,����''�`�.,�`=��-�,
Authorized Representative
farmers.com PolicyNo. 17607-74-36 Questions? Manage youraccount:
Call youragent Lydia L Chang at(626) Go to www.farmers.corn to access
205-8933 oremail youraccountanytime!
I li@farmersagent.com
56-6176 istEdition 5-17
Page 3 of 3