19-001 Phil Ackerly, Magician/Magic Show NO.
CITY Of FY2018-19
SHORT FORM ENTERTAINMENT AGREEMENT
CITY OF CUPERTINO
Recreation and Community Services Department
CUPERTINO 10185 N.Stelling Road
Cupertino, CA 95014
408-777-3120
--USE OF THIS FORM IS ONLY VALID FOR AGREEMENTS UP TO $3,500.00--
Contractor Name: PHIL ACKERLY
Contractor Authorized Representative: PHIL ACKERLY
By the signature of its Authorized Representative below, Contractor hereby agrees to the following:
A. SCOPE OF SERVICES.Contractor shall provide or furnish the following specified
services and/or materials:MAGICIANNAGIC SHOW
Location and Time of Contractor Services:
Location: JOLLYMAN PARK, 1000 S.STELLING ROAD, CUPERTINO,CA 95014
Time: 12 PM- 12:30 PM
B. TERM.The services and/or materials furnished under this Agreement shall be provided from
5/30/2019 to 5/30/2019.
C. COMPENSATION. For the full performance of this Agreement, the City of Cupertino shall
pay Contractor a total of$350.00 in a lump sum to be paid following receipt of Contractor's invoice.
D. EXHIBITS. The following attached exhibits hereby are made part of this Agreement:
✓Exhibit "C"-Affidavit of no Employees
✓ Exhibit"D"-Contractor's Mandated Reporter Declaration if Contractor provides services to children
GENERAL TERMS AND CONDITIONS
1. Indemnification. To the fullest extent allowed by law and except for losses caused by the sole
negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend, and
hold harmless the City, its City Council, boards and commissions, officers, officials, employees,
agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal
counsel acceptable to City, from and against any liability for damages, claims, actions, causes of
action, demands, charges, losses, costs and expenses (including attorney fees, legal costs and
expenses related to litigation, arbitrations, administrative and regulatory proceedings), of every
nature, arising out of or in any way related to Contractor's or Contractor's agents performance
of the Scope of Services. This includes but is not limited to liability resulting in personal injury,
death, property damage, or economic losses. Contractor must pay any costs City may incur in
enforcing this provision and must accept a tender of defense upon receiving notice from City.
Contractor's payments may be deducted or offset to cover any money the City lost due to a
claim or counterclaim arising out of this agreement.
2. General Liability Insurance: The undersigned shall maintain general liability insurance in an
amount not less than one million dollars ($1,000,000) per occurrence for bodily injury, personal
injury, and property damage. Undersigned's general liability policies shall be endorsed to
provide that City and its officers, officials, employees, and agents shall be additional insureds
under such policies.
3. Compliance with Laws. Contractor shall comply with all laws applicable to this Agreement
including, without limitation, laws regarding workers' compensation, antidiscrimination, and
conflict of interest. If Contractor has no employees an affidavit to that effect shall be attached to
this agreement. If the scope of work involves providing services to children, the City of
Cupertino, Consultant Declaration shall be attached
4. Assignment. Contractor may not assign, transfer, or subcontract this Agreement or any
portions thereof, without prior written consent of City.
5. Termination. City may terminate this agreement at any time. In the event of cancellation
within 24 hours of the time Contractor is to begin providing services City shall pay contractor
one half of the total agreement amount unless cancellation occurs after Contractor's personnel
have arrived at the location where services are to be performed in which case the total contract
amount shall be paid.
6. Interest of Contractor. It is understood and agreed that this Agreement is not a contract of
employment and, at all times, Contractor shall be deemed to be an independent contractor and
Contractor is not authorized to bind the City to any contracts or other obligations in executing
this Agreement. Contractor certifies that no one who has or will have any financial interest
under this Agreement is an officer or employee of City. City shall have no right of control as to
the manner Contractor performs the services to be performed. Nevertheless, City may, at any
time, observe the manner in which such services are being performed by the contractor.
Contractor shall comply with all applicable Federal, State, and local laws and ordinances
including, but not limited to, unemployment insurance benefits, FICA laws, and the City
business license ordinance.
7. Changes. No changes or variations of any kind are authorized without the written consent of
the City.
CONTRACT COORDINATOR and representative for CITY shall be: Marilu Mejia.
IN WITNESS WHEREOF, the parties have executed this Agreement effective the date last
signed below.
CONTRACTOR CITY OF CU E TINO
PHIL A� ERLY A Munici rporation
Bt
Y � By
Name /L Name Mpodka y -tb�
Title �
Title
Date
Date r i L q
Tax I.D. No.-
APPROVALS EXPENDITURE DISTRIBUTION;
RECREATION &COMMUNITY SERVICES DATE ACCOUNT NUMBER AMOUNT
DIRECTOR,
CITY ATTORNEY:APPROVED AS TO FORM DATE
CITY CLERK: ATTEST DATE
a 2-3 �9
March 28,2019
EXHIBIT C
AFFIDAVIT OF NO EMPLOYEES
State of California
County of Santa Clara
City of Cupertino
I, the undersigned, declare as follows:
I am an independent contractor and the owner of 77 2kAj A--L4�
I wish to enter into a services contract with the City of Cupertino. I am fully aware of the
provisions of section 3700 of the California Labor Code, which requires every employer to
provide Workers' Compensation coverage for employees in accordance with the provisions
of that Code. I am also aware that I must provide proof of workers' compensation insurance
to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the
City of Cupertino's contract.
I hereby certify that I do not have any employees nor will I have any employees working for
me or my business during the term of any service contract with the City of Cupertino. I am
not required to have Workers' Compensation insurance.
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct.
Executed on this day of at h �� California.
PRINT NAME
SIGNATURE
EXHIBIT D
Contractor's Mandated Reporter Declaration
The undersigned does hereby certify that:
1. I am a representative of PHIL ACKERLY that I am familiar with the facts herein and am
authorized and qualified to execute this declaration.
2. I declare that PHIL ACKERLY has complied with fingerprinting and criminal background
investigation requirements with respect to all Contractor's employees who may have
contact with minors in the course of providing services pursuant to the Agreement, and
the California Department of Justice has determined that none of those employees has
been convicted of a felony, as that term is defined in California Penal Code Section
11105.3.
3. I declare that each coach and administrator shall be required to successfully complete
concussion and head injury education at least once,either online or in person, before
supervising a participant, as required by California Health and Safety Code Section
124235, et seq.
4. On a yearly basis, all participants shall be required to sign and return a concussion and
head injury information sheet in compliance with California Health and Safety Code
Section 124235, which may be in the form attached as D-1.
5. That a complete and accurate list of Contractor's employees, who may come in contact
with minors during the course and scope of the Agreement, are included below.
6. All of the below mentioned employees have tested negative for TB, or X-ray results for TB,
and have current documentation on file with Contractor.
7. All of the below mentioned employees have received training and understand their
responsibilities under the Mandated Reporter laws of this state and are willing and able to
comply.
List of all Contractor Employees working for the City (if no Employees, identify "self"):
8. The Contractor will notify the City of Cupertino in writing of any new employees and
will be added to the above list prior to beginning work at the City of Cupertino.
I declare under penalty of perjury that the foregoing is true and correct.
PHIL ACKERLY
r
By: PHIL ACKERL
Title: ENTERTAINER
Date: ��
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.: 636934274860666775
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED)
Alliant Insurance Services,Inc.in conjunction with City of Cupertino
Apex Insurance Services
P.O.Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAMED INSURED(EVENT HOLDER): EVENT INFORMATION:
Phil Ackerly TYPE: Arts And Crafts(Various)
LOCATION: Jollyman Park,1000 South Stelling Rd,Cupertino,CA 95014
*Liquor Liability Yes C) Noe)
"Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy
period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless
amended as described in Special Conditions.
INSURANCE CARRIER:Evanston Insurance Company
MASTER POLICY NUMBER:
MASTER POLICY DATES: EFFECTIVE: January 01,2019 EXPIRATION: January 01, 2020
COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE
Aggregate Limit $2,000,000
Products&Completed Operations 1,000,000 SPECIAL CONDITIONS:
Personal&Advertising Injury 1,000,000 The following endorsements attached to
Each Occurrence Limit 1,000,000 the Master Policy do not apply to this
Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance:
Medical Payments(Any One Person) 5,000 MEGL1643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,00053,000,000
❑ $2,000,00052,000,000
Property Damage(If purchased)
No Property Damage Coverage
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
City of Cupertino, Its City Council, Boards and
Commissions, Officers, Officials, Employees,
Agents, Servants, Volunteers and Consultants
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy j
provisions.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED: 05/14/2019
A R C M F
INTERMEDIARIES
CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE
Form: SML Safeguard Wording-623AFB00213
Policy Number:
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: I"July 2018 To: I"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
I
b) USD 5,000,000 for all Claims for Wrongful Acts against all Victims,but j
sub-limited to:
c USD 50,000 for all Safeguard Costs resulting from all Circumstances
g g
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:
i
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 i
30 Batterson Park Road,
Farmington,
CT 06032.
c laims(iDbeazley.com
(860)677 3765(phone)
(860)679 0247(fax)
Retroactive Date:
i
IS`July 2018
Pending or Prior Litigation Date:
I51 July 2018
i
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: P June 2018
California Surplus Lines Notice 1-LMA9098A
Small Additional or Return Premiums 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 Limits Clause-LMA 3100
Beazley Safeguard Education Document
Arch Safeguard Enhancement Endorsement
Amended Definition of Independent Contractor Endorsement—as attached
U.S Classification:
Surplus Lines Broker and State filed in:Risk Placement Services,2850 Golf Road,
Rolling Meadows,IL 60008
License Number:OC66724
Information: Employees—41 full time+253 part time+63 IC's
Exposure Units—97,500
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%Lloyd's(Information about Lloyds)
AMENDED DEFINITION OF INDEPENDENT CONTRACTOR TO INCLUDE PART-TIME
INDEPENDENT CONTRACTORS
This endorsement modifies insurance provided under the following:
BEAZLEY SAFEGUARD
In consideration of the premium charged for this Policy, it is hereby understood and agreed that
Clause III. DEFINITION H. is deleted in its entirety and replaced with the following:
H. "Independent Contractor" means any natural person independent contractor who
performs labor or service for the Insured Organization on a full-time or part-time basis
pursuant to a written contract or agreement, where such labor or service is under the
exclusive direction of the Insured Organization. The status of an individual as an
Independent Contractor shall be determined as of the date of an alleged Wrongful Act.
All other terms and conditions of this Policy remain unchanged.
ENDORSEMENT.2 Attaching to and forming part of Certificate No.:
In the name of: City of Cupertino—Department of Recreation&Community Services
It is hereby understood and agreed that with effect from the 1st September 2018,within the Declarations
ITEM 1. Named Insured is amended to read as follows and not as previously stated:
ITEM 1. Named Insured: City of Cupertino—Department of Recreation&Community
Services;Public Works Department
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
DATED IN LONDON: 261 September 2018