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18-150 Wynn Kageyama, Class on Vehicular-Cycling Principle CITY OF \ SERVICES AGREEMENT ($59000 OR LESS) CUPERTINO 1. Parties. This Agreement("Agreement") is made and entered into as of 7/11/18 ("Effective Date")by and between the City of Cupertino, a municipal corporation("City") and Wynn Kageyama ("Contractor"), a Sole Proprietorship/Individual 2. Services. Contractor agrees to provide the programs, classes or activities ("Services") set forth in detail in the Scope of Services, attached and incorporated here as Exhibit A. 3. Time of Performance. This Agreement begins on the Effective Date and ends on ("Contract Time"),unless terminated earlier as provided herein. Contractor must deliver the Services in accordance with the Schedule of Performance included or attached to Exhibit A.Time is of the essence for the performance of all the Services. Contractor must have sufficient time, resources, and qualified staff to deliver the Services on time. 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 $385 ("Contract Price"),based upon the Scope of Services and the budget and rates included in Exhibit A. The maximum compensation includes all expenses and reimbursements and will remain in place even if Contractor's actual costs exceed the capped amount. Upon City approval of written invoices, Contractor will be paid as follows: (check one; cross out others): 0✓ A lump sum amount of$385 which shall not exceed the Contract Price. - - - -- O-At the rate of-$-- -per-hour for a total-not-to exceed the Contract Price:-- - --- -- - ❑Based on the payment schedule included or attached to Exhibit A which shall not exceed the Contract Price. 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. Contractor is not entitled to health benefits, workers compensation or other benefits from the City. Contractor must have the skills and qualifications to perform the Services in a competent and professional manner, and must be licensed, registered, and/or certified and have a City Business License. Contractor will supply all tools,materials and equipment required to perform the Services under this Agreement. 6. Assignment. This Agreement is not assignable. Contractor may not substitute another or transfer any rights or obligations under this Agreement without prior written approval of City. Only those persons whose names are included in Exhibit A may perform the-Services. Project Family Bike Education Workshop Services Agreement($5,000)/Rev.May 22, 2098 Page 1 of 6 7. Indemnification. To the fullest extent allowed by law and except for losses caused by the sole and active negligence or willful misconduct of City personnel, Contractor shall indemnify, defend, and hold harmless City, its City Council,boards and commissions, officers,officials, employees, agents, servants, volunteers and consultants ("Indemnitees"), through legal counsel acceptable to City, from and against any and all liability, damages, claims, actions, causes of action, demands, charges, losses, costs and expenses (including attorney fees, legal costs and expenses related to litigation and dispute resolution proceedings), of every nature, arising directly or indirectly from this Agreement or in any manner relating to any of the following: (a) Breach of contract, obligations,representations or warranties; (b) Negligent or willful acts or omissions committed during performance of the Services; (c) Personal injury,property damage, or economic loss resulting from the work or performance of Contractor or its subcontractors or sub-subcontractors; 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 Agreement. 8. Insurance. Contractor shall comply with the Insurance Requirements, attached and incorporated here as Exhibit B, and must maintain the insurance for the duration of the Agreement, or longer as required by City. City will not execute the Agreement until City approves receipt of satisfactory certificates of insurance and endorsements evidencing the type, amount, class of operations covered, and the effective and expiration dates of coverage. Failure to comply with this provision may result in City, at its sole discretion and without notice,purchasing insurance for Contractor and deducting the costs from Contractor's compensation or terminating the Agreement. 9. Compliance with Laws. Contractor shall comply with all laws and regulations applicable to this Agreement, included without limitation the following laws: Labor Laws. Contractor shall comply with all labor laws applicable to this Agreement. If the Scope of Services includes a"public works" component, Contractor is required to comply with prevailing wage laws under Labor Code Section 1720 and other labor laws. El Sole Proprietor. If Contractor is a sole proprietorship/individual, it must sign the Affidavit of No Employees included in this Agreement. Discrimination Laws. Contractor shall not discriminate on the basis of race,religious creed, color, ancestry, national origin, ethnicity, handicap, disability,marital status,pregnancy, age, sex, gender, sexual orientation, gender identity,Acquired-Immune Deficiency Syndrome (AIDS) or any other protected classification. Contractor shall comply with all anti-discrimination laws, including Government Code Sections 12900 and 11135, and Labor Code Sections 1735, 1777 and 3077.5. Consistent with City policy, Contractor understands that harassment and discrimination directed toward a j ob-applicant,an employee,-a City employee, or-any other persons-by Contractor or- Contractor's employees or sub-contractors will not be tolerated. Project Family Bike Education Workshop Services Agreement($5,000)/Rev.May 22, 2018 Page 2 of 6 Conflicts of Interest. Contractor shall comply with all conflict of interest laws applicable to this Agreement and must avoid any conflict of interest. Contractor warrants that no public official, employee,or member of a City board or commission who might have been involved in the making of this Agreement,has or will receive a direct or indirect financial interest in this Agreement,in violation of California Government Code Section 1090 et seq.. Contractor may be required to file a conflict of interest form if Contractor makes certain governmental decisions or serves in a staff capacity,as defined in Section 18700 of the California Code of Regulations. Contractor agrees to abide by the City's rules governing gifts to public officials and employees. 10.Abandonment.City may abandon or postpone the Project at any time. Contractor will be compensated for satisfactory Services performed through the date of abandonment. 11.Termination. City may terminate this Agreement for cause or without cause at any time. City reserves the right to terminate the Agreement and the remainder of the Services offered by Consultant without notice based upon Contractor's cancellation of a Service(i.e.,program,class or activity)without giving advance notice or obtaining written approval from City. 12. Governing Law.This Agreement is governed by the laws of the State of California.Any lawsuits filed related to this Agreement must be filed with the Superior Court for the County of Santa Clara, State of California.Contractor must comply with the claims filing requirements under the Government Code prior to filing a civil action in court. If a dispute arises,Contractor must continue to provide the Services pending resolution of the 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. 13.Entire Agreement.This Agreement represents the full and complete understanding of every kind or nature between the Parties,and supersedes any other agreement or understanding,either oral or written,between the Parties.Any changes to this Agreement will be effective only if in writing and signed by each Party's authorized representative. No verbal agreement or implied covenant will be valid to amend or abridge this Agreement. If there is any inconsistency between the main Agreement and the attachments or exhibits thereto,the text of the main Agreement shall prevail.Each provision and clause required by law for this Agreement is deemed to be inserted and will be inferredherein. 14. Services Coordinator. The Parties designate the following persons as Services Coordinators for this Agreement. Contractor's designation and any substitution are subject to City approval. For Contractor: For City: Wynn Kageyama David Stillman Name Name fez 4 114 3� ��.�c. Transportation Manager Position Position _ of JV 5 mkf :r s davids@cuperdno.org Contact Contact Project Family Bike Education Workshop Services Agreement($5,000)IRev.May 22,2018 Page 3 of 6 15. Contract Interpretation. There are no intended third party beneficiaries of this Agreement.Neither acceptance of the Services nor payment therefor shall constitute a waiver of any contract provision. City's waiver of a breach shall not constitute waiver of another provision or breach.Tfie headings in this Agreement are for convenience only. The Indemnification and Governing Law sections expressly survive this Agreement. 16. Severability. If a term or provision of the Agreement or its application to a particular situation is found by the court to be void, invalid, illegal or unenforceable, such term/provision shall remain in effect to the extent allowed by such ruling. All other terms and provisions of this Agreement or their application to specific situations shall remain in full force and effect. 17.Notices. All notices, demands, requests and approvals must be sent to the persons below in writing, and will be considered effective on the date of personal delivery, upon confirmation of delivery by a reputable overnight delivery service, on the fifth calendar day after deposit thereof in the United States Mail,postage prepaid, registered or certified, or the next business day following electronic submission: To City of Cupertino: To Contractor: 10300 Torre Ave.,Cupertino,CA 95014 Attention:Davud Stillman Attention:Wynn Kageyama Email:davids@cupertino.org Email: 18. Validity of Contract. This Agreement is valid and enforceable only if(a) it complies with the contract provisions of Cupertino Municipal Code Sections 3.22 and 3.23, (b) is signed by the City Manager or an authorized designee, and (c) is approved for form by the City Attorney's Office. 19. Execution. Contractor's signatory warrants that he or she is authorized to execute the Agreement and to legally bind Contractor. This Agreement may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. Project Family Bike Education Workshop Services Agreement($5,000)/Rev. May 22, 2018 Page 4 of 6 IN WITNESS WHEREOF, the Parties have caused the Agreement to be executed as of the Effective Date written above. CONTRACTOR CITY OF CUPERTINO A Municipal Corporation By: By: Name:Wynn Kageyama Name:David Stillman Title: . +t� '. " ~ `�� ji1; iL1 Title:Transportation Manager Tax I.D. No.: APPROVED AS TO FORM: -lei 1Y By: �� roc�! O FIERRO Cupertino Acting City Attorney ATTEST: r By: GRACE SCHMIDT, City Clerk Project Family Bike Education Workshop Services Agreement($5,000)/Rev. May 22,2018 Page 5 of 6 Ex. A: Scope of Work YMCA Workshops Dates: September 2211 and 23rd Scope of Work A subset of a grade 3-11 course that is 20 class sessions and about 15 hours in duration. Goal: Taught only with highly qualified instructors based on the vehicular-cycling principle, and based on scientific knowledge the successful participants will be guided to learn and use safe and useful cycling skills. The goal is supported by the following objectives: Objectives All students, adults and children will be able to perform some or all of the following: 1) To enable the student to undertake a range of useful trips considering the age and ability. 2) May or may not demonstrate these skills by undertaking a controlled driving test. 3) Develop an understanding of how the traffic system operates including driveway exiting, yielding, and riding on a two lane residential street. 4) Ten-year-olds to be introduced to riding on a multi-lane street with medium speed. 5) That for adults and parents,to be able to coach their child afterwards to reinforce the vehicular-cycling skills. 6) Even without formal knowledge, students will acquire the vehicular-cycling attitude. 7) The five basic traffic skills. 8) Mechanical safety 9) Yielding to cross traffic 10) Yielding to same direction traffic 11) Left turns 12) Intersection positioning 13) Lane changing 14) Lane changing, speed positioning Schedule A Scope of Work. W.Kageyama EXHIBIT B INSURANCE REQUIREMENTS For Services and Activities Involving Children Instructor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the Instructor, his agents, representatives, employees or subcontractors. 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 I j on an"occurrence"basis,including property damage,bodily injury and personal&advertising injury I with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location(ISO CG 25 03 or 25 04)or the general aggregate limit shall be twice the required occurrence limit. 2. Sexual Abuse/Molestation insurance or the equivalent are required for contracts involving children in after school activities, recreational programs, athletics, studies, transportation of students. Covers CA�l�( potential claims of abuse or child molestation. Sexual Abuse/Molestation coverage must be included �/" under General Liability or obtained in separate policies in an amount of not less than $1,000,000 per occurrence($2,000,000 aggregate)and $3,000,000 excess/umbrella coverage. 3. Automobile Liability: Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Instructor 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. (Note—required only if auto is usei erformanCe of work) 60 - Q�� � �° 4. Wor ers' Compensation_insurance as required by the State of California, with Statutory Limits, ` and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. (Note—required only if Instructor has employees). &uta ( Oma - d) If the contractor maintains broader coverage and/or higher limits than the minimums shown above,the Entity requires and shall be entitled to the broader coverage and/or higher limits maintained by the contractor.Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the Entity. Self-Insured Retentions Self-insured retentions must be declared to and approved by the Entity. The Entity may require the Instructor to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall provide,or be endorsed to provide, that the self-insured retention may be satisfied by either the named insured or Entity. Other Insurance Provisions The general liability policy is to contain, or be endorsed to contain,the following provisions: 1. The Entity, its officers, officials, employees, agents, and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Instructor including materials, parts or equipment furnished in connection with such work or operations. 2. For any claims related to this contract,the Instructor's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 20 0104 13 as respects the Entity, its officers, officials, employees, agents, and volunteers. 3. The Insurance Company agrees to waive all rights of subrogation against the Entity, its elected or appointed officers, officials, agents,and employees for losses paid under the terms of any policy which arise from work performed by the Instructor for the Entity. This provision also applies to the Instructor's Workers' Compensation policy. 4. Each insurance policy required above shall provide that coverage shall not be canceled,except with notice to the Entity. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best's rating of no less than A: VII,unless otherwise acceptable to the Entity. Verification of Coverage Instructor shall furnish the Entity with original certificates and amendatory endorsements effecting coverage required by this clause.All certificates and endorsements are to be received and approved by the Entity before work commences. The Entity 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. We strongly recommend obtaining a copy of the policy declarations and endorsement page(make this a requirement in your Contract)to facilitate verification of coverages and spot any undesirable policy limitations or exclusions. Homeowner's Insurance In some cases the Instructor's homeowner's liability insurance may provide coverage sufficient to meet these requirements. Instructor should provide these requirements to his or her agent to confirm and provide verification to the Entity. Special Events Coverage for Instructors Special events coverage is available for an additional fee to provide the liability insurance required by this agreement. Instructor can obtain additional information and cost from the Entity. Special or Low Risk Activities Entity reserves the right to modify these requirements, including limits, based on the nature of the risk,prior experience, insurer, coverage, or other special circumstances. The Entity reserves the right to modify or waive insurance requirements for certain low risk recreational activities. ,4coRD® CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) `.•�� 1 0770572018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: American Specialty Insurance&Risk Services,Inc. HON Ext); 260-969-5203 TF—AX Noll: 260-969-4729 dba A.S.I.R.S.I.Insurance Agency ADDRESS: 7609 W.Jefferson Blvd.,Suite 100 INSURER(S)AFFORDING COVERAGE NAIC# Fort Wayne IN 46804 INSURERA: Arch Insurance Company 11150 INSURED INSURER B: INSURER D: INSURER E: Washington DC 20006 INSURER F: COVERAGES CERTIFICATE NUMBER: 1001584899 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 i/ CLAIMS-MADE ❑X OCCUR DAMAGERENTED PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ Excluded A Y SBCGL0054501 02/01/2018 02/01/201 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIESPER: GENERALAGGREGATE $ 5,000,000 POLICY❑PROF-]LOC F PRODUCTS-COMP/OP AGG $ 5,000,000 OTHER: CLUB $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB IOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRI ETOR/PARTNER/EXECUTIVE ON/A E.LEACH ACCIDENT $ FFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage applies to WYNN KAGEYAMA #2142,423 BECADO DRIVE,FREMONT,CA 94539. -The Certificate Horder Shull be an Additional Insured,but onr with respect to the operations of the Named Insured,and suUj—ect to the provisions and limitations of Form OOS GL002900 Additional Insured-Designated Person or Organization Written Contract or Written Agreement,but only with respect to SMART CYCLING,SMART CYCLING ROAD COURSE,FAMILY BIKE SKILLS,FAMILY BIKE WORKSHOP from September 22,2018 through September 23, 2018. CERTIFICATE HOLDER CANCELLATION City of Cupertino,its'elected officials,employees and agents SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10300 Torre Avenue AUTHORIZED REPRESENTATIVE Cupertino CA 95014 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - CERTIFICATE HOLDERS SCHEDULE Additional Insured: City of Cupertino, its' elected officials, employees and agents 10300 Torre Avenue Cupertino, CA 95014 As of the effective date hereof, it is hereby understood and agreed that for the purposes of this endorsement, SECTION II - WHO IS AN INSURED is amended to include the Additional Insured identified in the above SCHEDULE, that is afforded coverage per Form OOS GL002900 Additional Insured - Designated Person or Organization Written Contract or Written Agreement, but only for liability arising out of the negligence of the Named Insured, Wynn Kageyama, SMART CYCLING, SMART CYCLING ROAD COURSE, FAMILY BIKE SKILLS, FAMILY BIKE WORKSHOP from September 22, 2018 through September 23, 2018. The Limits of Insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are part of, not in addition to, the Limits of Insurance shown in the Declarations. No change in premium All other terms and conditions of this Policy remain unchanged. Company:Arch Insurance Company Endorsement Number-1-01=- Policy Number: SBCGL005450.1 \ Na -Insured-League of American Wheelmen dba League of American Bicyclists Endorsement Effective Date: 09/22/18 President Issued by: GF July 10, 2018 00 ML0207 00 11 03 Page 1 of 1 A R C H � . �4 INTERMEDIARIES CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE Form: SML Safeguard Wording-623AFB00213 Policy Number: TBA Rene-wal 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: 1St July 2018 To: 1St 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 any one Victim b) USD 5,000,000 for all Claims for Wrongful Acts against all Victims,but sub-limited to: c) USD 50,000 for all Safeguard Costs resulting from all Circumstances Such Sub-limit of Liability 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 attachment Notification pursuant to Clause IX. shall be given to: Claims Department Beazley 30 Batterson Park Road, Farmington, CT 06032. claims<i beazley.com (860) 677 3765 (phone) (860) 679 0247(fax) Retroactive Date. - 1 St 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 California Surplus Lines Notice 1-LMA9098A Small Additional or Return Premiums Clause(U.S.A.)—NINIA 1168 Nuclear Incident Exclusion Clause-Liability-Direct—NMA 1256 Radioactive Contamination Exclusion Clause-Liability-NMA 1477 War and Terrorism Exclusion—NMA 2918 Sanctions Limits Clause-LMA 3100 Beazlgv Safeguard Education Document Arch Safeguard Enhancement Endorsement U.S Classification: Surplus Lines 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 subj ectivities to be received within 7 working days of binding otherwise Underwriters reserve the right to amend terms or cancel ab initio. Brokerage: 22.5%or same net equivalent downwards,plus taxes as applicable Tnfnrmatinn; Employees—36 full time+250 part time+ 63 IC's Exposure Units—97,000 Nature of Business—Municipality Cancellation by an Insured may result in a short rate calculation to determine the return premium, subject to 5%minimum earned of the total premium. Underwriting Security: 100%o Lloyd's(Information about Llovds) F " CSAA Insurance Exchange . k Automobile Policy Declarations �_ PO Box 22221 v7 IA— Oakland,CA 94623-2221 Please keep with your policy.See Important Notice on reverse. For questions or changes call:(800)922-8228 Page 1 of 2 1-Name and Address of Instsed Process 111111111111i1Jill.lp1111111151 O rType tl,aat� Renewal Certificate Date 03-13-2018 ` WYNN KAGEYAMA poky SiOwed 1979 NrAWGEORGINA g Named Insured,but not prior to the time applied Your 04-17-2018 for or.if this is a replacement declarations,not >- Policy prior to the time coverage change was requested. 0 Perwd To 12:01 A.M.Standard Tmre at the address of the a 04-17-2019 Named Insured. Alternate Address OxWation Alternate Nwnber Telephone Number Let 1 vehopetaraese coverdgc ........Ciabt7rty(units .....Item... ....ttem 2 .......Item 3 ........Item 4... ................. ....... Fach Person Eadr Occurrence Oeducoble Premium Dedixtibfe Deductible Premium Deductible Premium Bodily Injury 500,000 500,000 ..................................................... .................................................. Medical Payments 10,000 r ..................................................... ..............-------- --...... .....-...._.._....- Uninsured Motorists 500,000 500,000 .......................... ............... .................................................. Property Damage 100,000 ......................._..............------1-C-.. ...-...-.-.L"e*s---..:.............._..---...... omprehensive Actual Cash Value Less Deductible Full Comprehensive Safety Glass Endorsement ($0 deductible) .......................................................................................................... Collision Actual Cash Value Less Deductible .......................................................................................................... Enhanced Transportation Expense $25 per day/$750 aggregate 1 Risks Actual Cash Value Less Deductible No Cov4rage No Coverage No Cciverage No C&.erage Vehicle Loan/Lease Protection Endorsement No Cov4rage No Cokrage No Cckrage No Cckrage New Car Added Protection Endorsement No Coverage No Cokrage No Cdverage No Cclverage Original Equipment Manufacturer Parts(OEM)Endorsement No Cov4rage No Coverage No C&erage No C&erage Ride-sharing Coverage Endorsement No Coverage No Cotierage No Cclverage No Cckerage TOTAL PREMIUM PER VEHICLE ➢ $975 $507 $496 $1,101 *Automobile Death Benefits $15,000 per deceased insured person $6m Premium Summary This is not a bill. CA Surcharge: $0 Total Premium shown is for the Member AdvantageTm Program. EXCLUSIONS There is no coverage provided by this Polity while the following indivMdual(s)operate a motor vehicle: None schedule of changes LA W W Z Q u rs isao rz 1s Contractor's Affidavit of No Employees State of California County of Santa Clara City of Cupertino I,the undersigned, declare as follows: I am an independent contractor and the owner of 4;C-04- I wish to enter into a services contract with'the City of Cupertino. I aril 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 mast 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 'Z day of 2019,at t' y California. PWT AME S NATRE Select one