18-001 Michele Westlaken CITY OF
No.
FY2018-21
CUPERTINO
RECREATION SERVICES AGREEMENT
1. Parties. Tl1is contract is made a�1d entered uzto as of 7/6/2018 ("Effective Date"),by aizd
between the City of Cupertino, a municipal corporation ("City"), and wit11 MICHELE WESTLAKEN,
SAN JOSE, CA 95129 ("ConEractor"), a SOLE PROPRIETOR for
FELDENKRAIS.
2. Services. Contractor agrees to provide t11e Services uzcluded in the Scope of Work and
in accordance with the Schedule of Performance attached u1 Exhibit A.
3. Terrn. This contract begvzs on t11e Effective Date and ends on 6/30/2021 ("Contract
Tiine"), unless extended or terinuzated as provided 1-iereul. Tune is of the essence and Contractor must
have sufficient tiine, resources, and qualified staff to deliver t11e Services as required. Contractor must
prornptly notify Cify of any actual or potential delays to afford the Parties adequate opportunify 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$4,000 BETWEEN
7/6/2018 AND 6/30/2019, $4,000 SETWEEN 7/1/2019 AND 6/30/2020, AND $4,000 BET'WEEN 7/1/2020
AND 6/30/2021 ("Contract Price"), based upon the Scope of Services, budget, performance sclledule,
and rates included u1 Exhibit A. Tlze inaximuin compensation includes all costs, expenses and
reimbursements and will remaitl in place even if Contractor's actual costs exceed the capped amount.
Contractor must submit uzvoices and t11e uzformation required uz Exhibit A in order to receive payment.
City will coinpensate Contractor within 30 days after approval of written ulvoices.
Invoices are subject to review and audit by City durulg regular business 1lours upon 24-1lours'
notice. Contractor must maintain complete and accurate records of payrolls, expenditures,
disburseinents and other cost items charged to City or establishuzg fl1e basis for a�� ulvoice, for a
minimum of four (4) years from t11e date of final payment.
5. Independent Contractor.Contractor is an independent Contractor and not an einployee,
partner, or joint venture of City. Contractor is solely responsible for the inea�ls and inefllods of
performuZg the Services a�1d for the persons 1lired to worl<under t11is Agreeinent.No civil service status
or other right of elnployinent will be acquired by virtue of Contractor's performance of tlle Services.
Contractor is not entitled to City's 1lealth benefits, worker's compensation or atly other benefit.
Contractor must have the skills and qualifications to perforin the Services in a cornpetent and
professional manner. Contractor will supply all tools, materials and equipment required to perform
t11e Services under this Contract. Contractor is responsible for obtauling permits and licenses required
by law and must obtain a City business license.
Recreation Services Agree�nent/Rev. 3-27-2018
Page 1 of 6
6. Proprietary/Confidential Information. To the extent Contractor may 11ave access to
private or corLfidential information owned or controlled by the City, Contractor agiees to treat it
confidential atld use it solely to perforin this Agreeinent. Contractor inust exercise fl1e saine statldard
of care to protect City uzforination as a reasonably prudent Contractor would use to protect its own
proprietary data.
7. Ownership of Materials.To tlle extent Contractor prepares written material, drawuzgs
or data in coi�ulection with this contract, City wiIl 11ave the property rights to those materials and all
copyrights,if any, to such work product will constitute City property.
8. Records. Conhactor inust maintain complete,accurate, and detailed accotultulg records
relating to its performance uz accorda7lce with generally accepted accounting principles and
procedures. The records must include detailed ulforination about Contractor's services, bencllinarks,
deliverables and costs/fees,and inust be made reasonably available to City.T11e records and supporting
documents must be kept separate froin otller files and maultauzed for four years from fl1e date of City's
final payinent.
9. Assignmenf. This Contract is not assignable. Contractor inay not substitute another or
transfer a�zy rights or obligations under this Contract wifllout prior written approval of City.Only those
persons whose names are uzcluded i�1 Exhibit A may perform the Services.
10. Publicity and Signs.Any publicity generated by Contractor related to this contract or
the Services duruzg the Contract Tirne and for one year tllereafter inust reference City contributions.
The words "City of Cuperfino" shall be displayed in all pieces of publicity, including flyers, press
releases, posters, brochures, public service announceinents, 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 witllout prior written approval froin City.
1L Indernnification. To the fullest extent allowed by law a�1d except for losses caused by
the sole negligence or willful misconduct of City persorulel, Confi�actor agrees to indeinnify, defend,
and hold harinless the City, its City Couiuil, boards �Zd commissions, officers, officials, employees,
agents, servants, volunteers a�1d Contractors (collectively, "�ildemilitees"), througll legal counsel
acceptable to City, froin and against any liability for damages, claims, actions, causes of action,
delnatlds, charges, losses, costs and expenses (including attorney fees,legal costs and expenses related
to litigation, arbitrations, administiative and regulatory proceedings), of every nature, arisulg out of or
uz any way related to Cont�actor's or Contractor's agents perforinance of this contract or the Services.
Tl1is includes but is not limited to Liability resulting uz personal injury, death, property damage, or
economic Iosses. Contractor must pay any costs City may incur in enforcing this provision and inust
accept a tender of defense upon receivulg notice from City. Contractor's payinents inay be deducted or
offset to cover any inoney the City lost due to a claim or counterclaim arisuzg out of this Contract.
12. Insurance. Contractor shall comply with the insurance requireinents in Exhibit B. City
will not execute the Agreement until if has received and approved satisfactory certificates of uzsurance
and endorsements evidenculg the type, amowzt, and dates of coverage. Alternatively, City uz its sole
discretion inay purchase insurance and deduct the costs froin payinents to Contractor, or terinuzate the
contract. �
Recreation Services Agreement/Rev. 3-27-2018
Page 2 of 6
13. Cornpliance with Laws and Other City Requirements.
Requirements for all Contracts. This contract is subject to local, state and federal laws and
regulations prollibiting discriinulatioll,includitzg Title VII of the Civil Rights Act of 1964,�11e California
Fair Einployment Practices Act,the Ainericans with Disabilities Act of 1990,and other laws that pertaul
to fair einployinent a�zd anti-discrunulation practices. Contractor must comply witll labor laws
pertauzuzg to prevailuzg wages, workuzg hours, overti�ne, payroll records, and otller requirements
imposed by the Department of I�Zdustrial Relations.If Colltractor does not have einployees,it lnust sign
the Affidavit of No Employees, attached as Exhibit C. Contractor is respoYlsible for verifying
einployment eligibility of einployees pursuant to the Immigration Reforin and Control Act of 1986.
Contracfor must coinply wit11 conflict of ulterest laws and regulations applicable to this Agreeinent a�1d
avoid conflicts of i�lterest. Contractor may be required to file a cor�flict of interest forin for engaging in
governmental decisions or serving u1 a staff capacity, and is hereby advised to review the requirements
of California Political Reforin Act atzd the California Code of Regulations. Services may only be
performed by persons w110 are not einployed by City and who do not have a contzactual relationship
with City other t11an this contract. Contractor agrees to abide by City policies and admulistrative rules
prohibiting gifts to City officials and employees.
Additional Requirernents for Services Provided to Minors: Contractor and its einployees
who provide services under this Agreeinent inust comply with these additional requireinents:
A. Undergo fulgerprintvlg and a critninal background check a�1d verify all employees
providulg services wzder this contract have met tllis requirement.
B. Colnplete a Tuberculosis screening test as required by law and as set fortll u1 Exhibit D.
C. Coinply with the Matldatory Reporting under California Penal Code 11164-11174.3 alzd with
the protocols, reportuzg, and trainuzg required utlder California Health aizd Safety Code
Section 124235, AS2007, and other laws pertauzvzg to concussion evaluation, removal froin
play, and retur�l to play protocols. (Refer to Center for Disease Coni�ol & Prevelltion,
htt�s://www.cdc.gov/hea dsu�/index.11tml�.
D. Submit required forms and acicnowledgments uzcluded u1 Exhibit D, and ensure its eac11
participant is provided wit11 a concussion ulformation sheet, signs aizd returns the forms to
the City as required by Healtll and Safety Code Section 124235.
Require coaclles and administrators to successfully complete the concussion and 11ead uljury
education at least once either online or in person, before supervising a participant.
Contractor s11a11 offer frainulg, educational inaterials, or both to each Contractor
admu�istrator on a yearly basis. (Traululg resources are available at tl�e Center for Disease
Control&Prevelltion(link cited above).
E. If providuzg instruction, Contractor must acknowledge atld comply with all requirements
set forth uz the Recreation&Cominunity Services Insfructor Manual.
Checic one (if applicable):
❑ Tl1is contract requires services for children.
Recreation Services Ag�^eement/Rev. 3-27-2018
Page 3 of 6
� This contract currently does not requue services for cllildren. If in the future, services
for childrelz are required, the conhact will require a'written amendinent' to vzclude the
appropriate uzsurance coverages as requued 'u1`Exhibit B-I�lsurance Requirements for
Recreation Contracts', proof of fulger prultuzg and additional requireinents tulder
Paragrap1113. The contract ainendinent will also require t11e approval of the Director of
Recreation and CoiYununity Services and City Attorney.
14. Coordination of Services. The Parties designate the followulg persons as Services
Coordulators wit11 t11e responsibility to oversee fl1e delivery of Services u1 accordance with fl1e terins of
this Agreeinenf. Contractor's designation and atly substitution are subject to City approval.
For City: For Contractor:
Naine:Jason Bisely Naine:Midlele Westlaken
Position: Recreatiolz Coord'uzator Position: Instructor
Contact:jasonb@cut�ertino.org;408.777.3150 Contact:
15. Abandonment. City inay abandon or postpone the Activity or Program and will notify
Contractor as soon as possible. Contractor will be paid for satisfactory Services rendered through t11e
date of aba�zdoiunent upon subinission of fuzal uzvoices approved by City.
16. Terrnination. City inay terinulate tl-iis 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 subinission of fvzal uzvoices approved by City.
17. Governing Law,Venue and Dispute Resolution.T11is contract is governed by the laws
of t11e State of California. Any legal actions or proceeduzgs filed againsf City u1 corulection with this
contract must comply with the governinent claims filulg requireinents and inust be filed witll t11e
Superior Court for fl1e County of Santa Clara, State of California. At City's request, Contractor is
required to contulue to provide Services pending resolution of aily dispute. If tlle Parties elect
arbitration, the arbitrator's award inust be supported by law and substantial evidence and include
detailed written fuldulgs of law and fact.
18. Attorney Fees. If City is required to pursue litigation,arbitration or other admuzistrative
or regulatory proceedulg to enforce its rights or fl1e terins of this Agreement, the prevailulg party will
be entitled to reasonable attorney fees and costs. This Section survives t11is Agreeinent.
19. Third Party Beneficiaries.There are no third party beneficiaries wzder this Contract.
20. Waiver. Neither acceptance of Services nor payinent thereof constitutes a waiver of a�1y
contract provision. City waiver of a breach shall not constitute waiver of anotller term, provision,
covenant or condition, or a subsequent breach,whether of the saine or a different character.
21. Entire Agreement. This Agreelnent and all referenced Exhibits are hereby attached and
incorporated into the Agreeinent by this reference aild represent the full and complete understanding
as to fhose matters contauled herevl, and supersede any other contract or wzderstandulg, eitller oral or
Rec��eation Se�^vices Agi^eement/Rev. 3-27-2018
Page 4 of 6
written,between t11e Parties.This Agreeinent inay not be rnodified or ainended except u1 writulg signed
by both Parties.If tllere is any vzconsistency between the inaul conh act and any attaclunents or e�ibits
thereto, the maul confract shall prevail.
22. Inserted Provisions.Eac11 provision or clause required by law or this contract is deeined
to be ulcluded and will be inferred hereul. Either party inay request a�1 amendinent to cure any
inistaken uzsertion or oinission of a required provision.
23. Headings. Tl1e 1leadulgs are for convenience only and are not a part of the contract or
ultended to affect, liinit or atnplify tlle terms or provisions of tliis Agreeinent.
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, uzvalid, illegal or unelzforceable, suc11 term or
provisioiz shall remaul u1 force a�1d effect to the extent allowed by suc11 ruling. All otller contract terins
and provisions and their application to specific situations will remain i�z full force and effect.
25. Survival.All provisions whicll by their nature inust contuzue after t11e Agreement ends,
including without limitation Tizdeiruzification, I�zsurance, Ownership of Materials,Records, Governulg
Law a�zd Attoi�ney Fees,will survive the expiration or terinulation of this Agreeinent.
26. Notices.A11 notices and it�isfruments pertauzuzg to inaterial provisions of this contract or
significant disputes w11icI1 are required by law or under this contract to be u1 writulg must be sent to
t11e persons lisfed below. T11e notices will be deeined effective on the date of personal delivery or t11e
date confirmed by a reputable overnight delivery service, on the fifth calendar day after deposit u1 t11e
United States Mail, postage prepaid, registered or certified, or the next busuless day following
electronic subinissioil.
To City of Cupertuzo: To Contractor:
Office of the City Ma�zager 1158 Hwztuzgdon Drive,San jose, CA 95129
10300 Torre Ave., Cupertino CA 95014 cc: Represerltative/Coordulator:
cc: Representative/Coordinator: Michele Westlaken
jason Bisely Email:
Email: jasonb@cupertulo.org
27. Validity of Contract. T12is contract is valid and enforceable only if it coinplies with t11e
provisions of Cupertuzo Mwlrcipal Code Chapters 3.22 and 3.23, is signed by the City Ma�zager or
autl�orized 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 fllat Contractor 11as full right, power, and authority to execute t11is contract and to carry out
all actions and services required. Tl1is contract constitutes a legally buzding obligation of Contractor,
alzd may be executed in cowlterparts, each one of which is deemed an origulal and all of which, taken
together, constitute a single bulding instruinent.
Recreation Se�^vices Agreement/Rev. 3-27-2018
Page 5 of 6
IN WITNESS WHEREOF,the parties have caused this confi�act to be executed.
CONTRACTOR CITY OF CUPERTINO
Michele Westlaken A Municipal Corporation
B �'_— By ..,,�
Naine Ch�,R Q �' Naine��JC/J���1Co �i�/
Title ����ct,lS �?�i�� Title ���-I /��'C-C:�Z1r'
Date �l L�.a., (2-��� Date `d' �c���t�
Tax I.D. No.: Re{er to W-9
. ��I�
�-
APPROVED AS TO FO�� � � � �f� ��' ATTEST:
� ��- �J
� �`�,
�/ �1 . _��
,�ND�H---�T�-�P�SC-�-��0� GRACE SCHMIDT ,.� �--;��
pertuzo City Attorney � City Clerk
/ �
Cont��actlEncumbered A�nount:$12,000
Account No.: 100-G2-623 700-702
RecT^eation Services Agreen�ent/Rev. 3-27-2 DI S
Page 6 of 6
EXHIBIT A
SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide FELDENKRAIS INSTRUCTION in,but not lirnited to,the
following:
FELDENKRAIS METHOD
Location and Tirne of CONTRACTOR Services:
Refer to the Senior Center Newsletters dated jULY/AUGUST 2018,SEPTEMSER/OCTOBER 2018,
NOVEMBER/DECEMSER 2018,JANUARY/FEBRUARY 2019, MARCH/APRIL 2019, MAY/JUNE
2019,JULY/AUGUST 2019, SEPTEMBER/OCTOBER 2019, NOVEMSER/DECEMSER 2019,
JANUARY/FEBRUARY 2020, MARCH/APRIL 2020, MAY/JUNE 2020,JULY/AUGUST 2020,
SEPTEMBER/OCTOSER 2020, NOVEMBER/DECEMBER 2020,JANUARY/FEBRUARY 2021,
MARCH/APRIL 2021,AND MAY/JUNE 2021 for agreed upon dates, tiines, and class locations. The
City, at its sole discretion,inay cllange t11e agreed terins.
Compensation for CONTRACTOR Services:
Contractor shall be compensated for services performed pursuant to this Agreement. Compensation
shall consist of t11e followitlg: EIGHTY-SEVEN AND A HALF PERCENT(87.5%) OF REVENUE
GENERATED PER SESSION PLUS SIXTY PERCENT(60%) OF THE REVENUE FOR DROP IN PASSES.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 MARI<ERS,ERASERS,AND HANDOUTS.COPY SERVICE AT THE SENIOR CENTER IS$0.10 PER
PAGE. T11e total coinpensation to the Contractor s11a11 not exceed$12,000.
Eligible Participant Minirnum and Maximurns for CONTRACTOR Services:
Mulunuin: 3
Maxiinum: 15
If less tha�z the required mulimum number of participailts eruoll u1 and pay for a particular class as
identified in the schedule before the class is scheduled to start, the City inay cancel the particular class
and/oi terrninate this Agreement without additional notice or paylnent to Contractor.
List of all Contractor Employees worlcing for the City of Cupertino (if no Employees,identify
"self"):
SELF
Performance of CONTRACTOR Services:
I�Z fl1e case Contractor wzilaterally cancels performance of a class, cainp, activity or service without
City approval, City reserves the right to iinmediately alzd without notice cancel the reinauzder of
programs/services offered and or performed by Contractor.
The Contractor shall follow all guidelules pertaulvlg to registration procedures as listed u1 t11e
quarterly recreation schedule. Participants lnay not take part in the prograin unless they are listed on
t11e class roster or can s11ow proof of enrollment. All participants and volwzteers need to complete the
City's Waiver of Liability forin prior to takulg part u1 t11e program. If applicable, contractors who are
responsible for supervisulg ininors inust rema'v1 with the class until a parent of legal guardian 11as
arrived and all inuzors are released to them.
In the event of an uzjury occurrulg to a participant, t11e Contractor will notify t11e City wi�lluz 1 hour
and coinplete an Incident Report in t11e form approved by the City. T11e I�lcident Report must be
subinitted to fhe City with"vz 24 hours of the uzjury occurring.
` Exhibit B i
Insut�a»ce Requi��et�aents fot�Rec�eation Co�atf°acts
As required by Section 12 of the Agreement, Contractor shall prociue and maintain the following insurance
for the duration of the contract against claims arising from or in coiu7ection with Contractor, its agents,
representatives, employees or subcontractors Sei-vices under this Agreement.
Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as:
l. Commercial General Liability (CGL): Insurance Services Office Form CG 00 O1 covering CGL on an
"occunence" basis, including property damage, Uodily injury and personal & advertising injury with
liinits no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply
separately to tivs project/location(CG 25 03 or 25 04) or be twice the required occui�ence 1u11it.
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 linuts no less than$1,000,000 per accident for bodily injury and
property damage.
❑ Requi�ed if automobile is used to perfo�^T�2 woriz ui�de�this cont�act.
;°� Otlze�wise, �roof of Contractor's pev�sonal auto insura��ce with limits requi�ed by stczte law
suffices. Cont�acto�^shall not trans�ov�t oN use its personal vehicle to tra�zsport pa�^ticipa��ts o�^
�e�foNm wo�Iz 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 injuiy or disease.
❑ Requi�ed if Cont�actor has einployees.
� If no e�n�loyees, Contractor rsaust sign Affidavit of No Einployees.
4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/sei-vices involving
minors, (i.e., after school activities, recreational programs, atl�letics, study/training events and
transportation of minors). Coverage inay 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.
❑ Requi�ed if Conti�act involves services to childr�en.
Insurance coverage required inay ve satisfied by a combination of Priinary and Excess/LTmbrella insurance.
Self-b2su��ed Rete�itio�is: Self-insured retentions must be approved by City. City may require Contractor to
provide proof of aUility to pay losses and related investigations, claim adiniiustration, and defense
expenses within the retention. The policy language must provide, or be endorsed to provide, that the self-
insured retention may Ue satisfied by either the named insured or City.
Acceptability of Insur^ers:Insurance must be issued by insurers acceptaUle 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
ratiilg 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 InsuYal2ce for Recreation Contracts Updated 3-26-18
1
operations perfonned by or on Uehalf of the Contractor including materials, parts or equipment
fui7lished in comlection 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
appointed officers, officials, agents, and employees for losses paid under the tei7ns of any policy
which arise from worlc perfonned by Contractor for City. Tlus 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.
Pr�inaary Cove�^age: The Additional Insured coverage under Contractor's policy shall Ue primary non-
contributory and at least as broad as ISO CG 20 O1 04 13 as respects the City and all the
insureds/indenuutees. If the limits of insurance required are satisfied in part by Umbrella/Excess Insurance,
the UmUrellaBxcess 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 Caricellatio�z: 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
premiuins. Such notice must be sent to City via email or cei-tified inail to the attention of the City Manager.
Waive��of Sub��ogatio�z: Contractor grants City a waiver of any right to subrogation which any insurer of said
Contractor may acquire against City Uy virtue of payinent of any loss under such insurance. Contractor will
obtain any endorsement that may Ue necessary to effect tlus waiver of suUrogation, Uut this provision applies
regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer.
Yerification of Cove�^age:Contractor shall furnish the City with origulal certificates and amendatory
endorseinents effecting coverage required by this clause. All certificates and endorseinents are to be received
and approved Uy the City Uefore work conunences. 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 �ld endorsement page verifying the required ulsurance coverages.
Ho»Zeowner's bZsu�^a�2ce: Contractor's homeowner's liability insurance may provide coverage sufficient to
meet these requirements. Contractar should provide these requirements to lus or her agent to confirm and
provide veri�ication to City.
� Special Eve�zts Coverage:Insurers inay 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 Circunzstce�zces:City reserves the right to modify these requirements based on the nature of
the rislc,prior experience, insurer, coverage, or other special circumstances.
Exlz.B Insurance for Recreation Co�at�acts Updated 3-26-18
2
EXHIBIT C
AFFIDAVIT OF NO EMPLOYEES
State of California
County of Santa Cla��a .
City of Cupertino
I, the undersigned, declare as follows:
I am an independent contractor and t11e owner of_ �IG►�i�,W�s'���(�v�—
I wish to enter into a services contract with the City of Cupertino. I ain 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 piovisions
of that Code. I am also awaie that I inust provide proof of workeis' compensation insurance
to the Cify of Cupertino for any and all employees I may have, pursuant to Section 12 of the
City of Cupertino's contract.
I hereby certify t11at I do not have any employees nor will I have any employees worl<ing for
me or iny business duiing the term of any service contract with the City of Cupertino. I am
not required to have Worl<ers' 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 4Lday of J�w-- , 2018, at U �✓��� California.
�U� W�'�`f 1 G�+�.e--
PRINT NAME
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ADDITIONAL INSURED COVERAGE VERIFICATION
Insured: Enrolled Member Effective Date:
American Massage Therapy Association
500 Davis Street 01/01/2018
Evanston, IL 60201 To
Master Policy Number: HPG 0289955556
01/01/2019
Enrolled Member Name and Address:
Administered Bv:
Michele Westlaken Healthcare Providers Service Organization
Affinity Insurance Services, Inc.
159 East County Line Road
San Jose, CA 95129-3123 Hatboro, PA 19040
Insurance Companv:
Columbia Casualty Company
A CNA Compan
Additional Insured: Limits
City of Cupertino, its Council, Boards, and Commissions, Each Claim: $2,000,000
Aggregate: $6,000,000
officers, employees, &Volunteers Fire&Water Legal Liability sublimit:$100,000
10300 Torre Ave., Subject to the Master Policy Aggregate
Cupertino,CA 95014
X Professional Liabilitv Coveraqe Extension for Additional Insureds
The coverage set forth in Section I, Coverage Agreement is extended to any additional insured but only as respects such
additional insured's liability arising out of a medical incident by the enrolled member, and solely to the extent that:
1. a professional liability claim is made against the enrolled member and the additional insured;and
2. in any ensuing litigation arising out of such claim, the enrolled member and the additional insured remain as co-
defendants.
In no event is there any coverage provided under this policy for acts, errors or omissions of the additional insured.
Additional Insured means any person or entity that an enrolled member is required to add as an additional insured by written
contract or agreement for professional services.The written contract or agreement must be:
1. Currently in effect or become effective during the term of the enrolled member's certificate period; and
2. Executed prior to the injury or damage.
X General Liabilitv Coveraqe Extension for Additional Insureds
The coverage set forth in Section I, Coverage Agreement is extended to any additional insured but only as respects such
additional insured's liability arising out of premises they own, maintain or control while the enrolled member leases or occupies
these premises, and solely to the extent that:
1. a general liability claim is made against the enrolled member and the additional insured; and
2. in any ensuing litigation arising out of such claim,the enrolled member and the additional insured remain as co-
defendants.
In no event is there any coverage provided under this policy for an occurrence that is the direct liability of the additional insured.
The written contract or agreement must be:
1. Currently in effect or becoming effective during the term of this policy; or
2. Executed prior to the injury or damage.
Additional Insured means any person or entity that an enrolled member is required to add as an additional insured by written
contract or agreement.
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