18-001 Lisa MolaroCITY OF
No.
a FY2018-20
CUPERTINO
RECREATION SERVICES AGREEMENT
1.Parties.This contract is made and entered into as of 7/16/2018("Effective Date"),by and
between the City of Cupertino, a municipal corporation ("City"), and with LISA MOLARO,
("Contractor"), a SOLE PROPRIETOR for YOUTH ART
INSTRUCTION.
2.Services. Contractor agrees to provide the Services included in the Scope of Work and
in accordance with the Schedule of Performance attached in Exhibit A.
3. Term. This contract begins on the Effective Date and ends on 6/30/2020 ("Contract
Time"),unless extended or terminated as provided herein.Time is of the essence and Contractor must
have sufficient time, resources, and qualified staff to deliver the Services as required. Contractor must
promptly notify City of any actual or potential delays to afford the Parties adequate opportunity to
address or mitigate such delays.
4.Compensation. City will pay Contractor for satisfactory performance of the Services an
amount that will based upon actual costs but that will be capped so as not to exceed $70,000("Contract
Price"),based upon the Scope of Services,budget,performance schedule, and rates included in Exhibit
A. The maximum compensation includes all costs, expenses and reimbursements and will remain in
place even if Contractor's actual costs exceed the capped amount.Contractor must submit invoices and
the information required in Exhibit A in order to receive payment. City will compensate Contractor
within 30 days after approval of written invoices.
Invoices are subject to review and audit by City during regular business hours upon 24-hours'
notice. Contractor must maintain complete and accurate records of payrolls, expenditures,
disbursements and other cost items charged to City or establishing the basis for an invoice, for a
minimum of four(4) years from the date of final payment.
5. Independent Contractor.Contractor is an independent Contractor and not an employee,
partner, or joint venture of City. Contractor is solely responsible for the means and methods of
performing the Services and for the persons hired to work under this Agreement.No civil service status
or other right of employment will be acquired by virtue of Contractor's performance of the Services.
Contractor is not entitled to City's health benefits, worker's compensation or any other benefit.
Contractor must have the skills and qualifications to perform the Services in a competent and
professional manner. Contractor will supply all tools, materials and equipment required to perform
the Services under this Contract. Contractor is responsible for obtaining permits and licenses required
by law and must obtain a City business license.
Recreation Services Agreement/Rev. 3-27-2018
Page 1 of 6
6. Proprietary/Confidential Information.To the extent Contractor may have access to
private or confidential information owned or controlled by the City, Contractor agrees to treat it
confidential and use it solely to perform this Agreement. Contractor must exercise the same standard
of care to protect City information as a reasonably prudent Contractor would use to protect its own
proprietary data.
7. Ownership of Materials.To the extent Contractor prepares written material,drawings
or data in connection with this contract, City will have the property rights to those materials and all
copyrights,if any,to such work product will constitute City property.
8. Records.Contractor must maintain complete,accurate,and detailed accounting records
relating to its performance in accordance with generally accepted accounting principles and
procedures. The records must include detailed information about Contractor's services,benchmarks,
deliverables and costs/fees,and must be made reasonably available to City.The records and supporting
documents must be kept separate from other files and maintained for four years from the date of City's
final payment.
9. Assignment,This Contract is not assignable.Contractor may not substitute another or
transfer any rights or obligations under this Contract without prior written approval of City.Only those
persons whose names are included in Exhibit A may perform the Services.
10. Publicity and Signs.Any publicity generated by Contractor related to this contract or
the Services during the Contract Time and for one year thereafter must reference City contributions.
The words "City of Cupertino" shall be displayed in all pieces of publicity, including flyers, press
releases, posters, brochures, public service announcements, umterviews and newspaper articles. No
signs may be posted,exhibited or displayed on or about City property,except signage required by law
or under this Agreement without prior written approval from City.
11. Indemnification.To the fullest extent allowed by law and except for losses caused by
the sole negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend,
and hold harmless the City, its City Council, boards and commissions, officers, officials, employees,
agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal counsel
acceptable to City, from and against any liability for damages, claims, actions, causes of action,
demands,charges,losses,costs and expenses(including attorney fees,legal costs and expenses related
to litigation,arbitrations,administrative and regulatory proceedings),of every nature,arising out of or
in any way related to Contractor's or Contractor's agents performance of this contract or the Services.
This includes but is not limited to Liability resulting in personal injury, death, property damage, or
economic losses. Contractor must pay any costs City may incur in enforcing this provision and must
accept a tender of defense upon receiving notice from City.Contractor's payments may be deducted or
offset to cover any money the City lost due to a claim or counterclaim arising out of this Contract.
12. Insurance.Contractor shall comply with the insurance requirements in Exhibit B.City
will not execute the Agreement until it has received and approved satisfactory certificates of insurance
and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole
discretion may purchase insurance and deduct the costs from payments to Contractor,or terminate the
contract.
Recreation Services Agreement/Rev.3-27-2018
Page 2 of 6
i
13. Compliance with Laws and Other City Requirements.
Requirements for all Contracts. This contract is subject to local, state and federal laws and
regulations prohibiting discrimination,including Title VII of the Civil Rights Act of 1964,the California
Fair Employment Practices Act,the Americans with Disabilities Act of 1990,and other laws that pertain
to fair employment and anti-discrimination practices. Contractor must comply with labor laws
pertaining to prevailing wages, working hours, overtime, payroll records, and other requirements
imposed by the Department of Industrial Relations.If Contractor does not have employees,it must sign
the Affidavit of No Employees, attached as Exhibit C. Contractor is responsible for verifying
employment eligibility of employees pursuant to the Immigration Reform and Control Act of 1986.
Contractor must comply with conflict of interest laws and regulations applicable to this Agreement and
avoid conflicts of interest. Contractor may be required to file a conflict of interest form for engaging in
governmental decisions or serving in a staff capacity,and is hereby advised to review the requirements
of California Political Reform Act and the California Code of Regulations. Services may only be
performed by persons who are not employed by City and who do not have a contractual relationship
with City other than this contract.Contractor agrees to abide by City policies and administrative rules
prohibiting gifts to City officials and employees.
Additional Requirements for Services Provided to Minors: Contractor and its employees
who provide services under this Agreement must comply with these additional requirements:
A. Undergo fingerprinting and a criminal background check and verify all employees
providing services under this contract have met this requirement.
B. Complete a Tuberculosis screening test as required by law and as set forth in Exhibit D.
C. Comply with the Mandatory Reporting under California Penal Code 11164-11174.3 and with
the protocols, reporting, and training required under California Health and Safety Code
Section 124235, AB2007, and other laws pertaining to concussion evaluation,removal from
play, and return to play protocols. (Refer to Center for Disease Control & Prevention,
https://www.cdc.gov/headsul2/index.htmil.
D. Submit required forms and acknowledgments included in Exhibit D, and ensure its each
participant is provided with a concussion information sheet, signs and returns the forms to
the City as required by Health and Safety Code Section 124235.
Require coaches and administrators to successfully complete the concussion and head injury
education at least once either online or in person, before supervising a participant.
Contractor shall offer training, educational materials, or both to each Contractor
administrator on a yearly basis. (Training resources are available at the Center for Disease
Control&Prevention(link cited above).
E. If providing instruction, Contractor must acknowledge and comply with all requirements
set forth in the Recreation&Community Services Instructor Manual.
Check one(if applicable):
N This contract requires services for children.
Recreation Services Agreement/Rev.3-27-2018
Page 3 of 6
This contract currently does not require services for children. If in the future, services
for children are required,the contract will require a'written amendment'to include the
appropriate insurance coverages as required in'Exhibit B—Insurance Requirements for
Recreation Contracts', proof of finger printing and additional requirements under
Paragraph 13. The contract amendment will also require the approval of the Director of
Recreation and Community Services and City Attorney.
14. Coordination of Services. The Parties designate the following persons as Services
Coordinators with the responsibility to oversee the delivery of Services in accordance with the terms of
this Agreement. Contractor's designation and any substitution are subject to City approval.
For City: For Contractor:
Name: Daniel Mestizo Name: Lisa Molaro
Position: Recreation Coordinator Position: Instructor
Contact: danielm@cupertino.org 1 408-777-3134 Contact:
15. Abandonment.City may abandon or postpone the Activity or Program and will notify
Contractor as soon as possible. Contractor will be paid for satisfactory Services rendered through the
date of abandonment upon submission of final invoices approved by City.
16. Termination. City may terminate this contract for cause or without cause at any time
and will notify Contractor as soon as possible.Contractor will be paid for satisfactory services rendered
through the date of termination upon submission of final invoices approved by City.
17. Governing Law,Venue and Dispute Resolution.This contract is governed by the laws
of the State of California. Any legal actions or proceedings filed against City in connection with this
contract must comply with the government claims filing requirements and must be filed with the
Superior Court for the County of Santa Clara, State of California. At City's request, Contractor is
required to continue to provide Services pending resolution of any dispute. If the Parties elect
arbitration, the arbitrator's award must be supported by law and substantial evidence and include
detailed written findings of law and fact.
18. Attorney Fees. If City is required to pursue litigation,arbitration or other administrative
or regulatory proceeding to enforce its rights or the terms of this Agreement, the prevailing party will
be entitled to reasonable attorney fees and costs. This Section survives this Agreement.
19. Third Party Beneficiaries.There are no third party beneficiaries under this Contract.
20. Waiver. Neither acceptance of Services nor payment thereof constitutes a waiver of any
contract provision. City waiver of a breach shall not constitute waiver of another term, provision,
covenant or condition, or a subsequent breach whether of the same or a different character.
21. Entire Agreement.This Agreement and all referenced Exhibits are hereby attached and
incorporated into the Agreement by this reference and represent the full and complete understanding
as to those matters contained herein, and supersede any other contract or understanding,either oral or
Recreation Services Agreement/Rev.3-27-2018
Page 4 of 6
written,between the Parties.This Agreement may not be modified or amended except in writing signed
by both Parties.If there is any inconsistency between the main contract and any attachments or exhibits
thereto,the main contract shall prevail.
22. Inserted Provisions.Each provision or clause required by law or this contract is deemed
to be included and will be inferred herein Either party may request an amendment to cure any
mistaken insertion or omission of a required provision.
23. Headings. The headings are for convenience only and are not a part of the contract or
intended to affect,limit or amplify the terms or provisions of this Agreement.
24. Severability/Partial Invalidity.If any contract term or provision,or their application to
a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or
provision shall remain in force and effect to the extent allowed by such ruling. All other contract terms
and provisions and their application to specific situations will remain in full force and effect.
25. Survival.All provisions which by their nature must continue after the Agreement ends,
including without limitation Indemnification,Insurance,Ownership of Materials, Records,Governing
Law and Attorney Fees,will survive the expiration or termination of this Agreement.
26. Notices.All notices and instruments pertaining to material provisions of this contract or
significant disputes which are required by law or under this contract to be in writing must be sent to
the persons listed below. The notices will be deemed effective on the date of personal delivery or the
date confirmed by a reputable overnight delivery service,on the fifth calendar day after deposit in the
United States Mail, postage prepaid, registered or certified, or the next business day following
electronic submission.
To City of Cupertino: To Contractor:
Office of the City Manager
10300 Torre Ave.,Cupertino CA 95014 cc: Representative/Coordinator:
cc: Representative/Coordinator: Lisa Molaro
Daniel Mestizo Email:
Email: danielm@cupertino.org
27. Validity of Contract.This contract is valid and enforceable only if it complies with the
provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or
authorized designee,and is approved for form by the City Attorney's Office.
28. Execution. The person executing this contract on behalf of Contractor represents and
warrants that Contractor has full right, power, and authority to execute this contract and to carry out
all actions and services required. This contract constitutes a legally binding obligation of Contractor,
and may be executed in counterparts,each one of which is deemed an original and all of which,taken
together,constitute a single binding instrument.
Recreation Services Agreement/Rev.3-27-2018
Page 5 of 6
IN WITNESS WHEREOF, the parties have caused this contract to be executed.
CONTRACTOR CITY OF CUPERTINO
Lisa Molaro A Municipal Corporation
By C JVtJ By
Name b 011,1 Nam n' ahl c, G1
Title 6 Z J(J1 Title
Date Date
Tax I.D. o.:refer to W-9 on file
APPROVED AS TO FORM: ATTEST:
LPH STEVENSON HOM GRACE SCHMIDT
Cu o City Attorney City Clerk
ContractlEncumbered Amount:$70,000
Account No.:580-62-613 700-702
Recreation Services Agreement/Rev.3-27-2018
Page 6 of 6
EXHIBIT A
SCOPE OF WORK, PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide YOUTH ART INSTRUCTION in,but not limited to, the
following:
ART CAMPS, CREATE TOGETHER, CLAY YOUR WAY, HOMESCHOOL ART FOCUS,
TEEN POTTER'S WHEEL, CERAMIC PARTIES, CERAMIC CAMPS, ART WORKSHOPS
Location and Time of CONTRACTOR Services:
Refer to the Recreation Schedule dated SUMMER 2018-SUMMER 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 compensated for services performed pursuant to this Agreement. Compensation
shall consist of the following: Classes,Camps, Workshops: 60%of the resident fee based on final class
rosters.Ceramic Parties: 75%of total ceramic party fees collected.
The total compensation to the Contractor shall not exceed$70,000.
Eligible Participant Minimum and Maximums for CONTRACTOR Services:
Minimum: 4
Maximum: 20
If less than the required minimum number of participants enroll in and pay for a particular class as
identified in the schedule before the class is scheduled to start, the City may cancel the particular class
and/or terminate this Agreement without additional notice or payment to Contractor.
List of all Contractor Employees working for the City of Cupertino (if no Employees,identify
self"):
1A 0j C-d ne- M b 1. a-
Performance of CONTRACTOR Services:
In the case Contractor unilaterally cancels performance of a class, camp,activity or service without
City approval,City reserves the right to immediately and without notice cancel the remainder of
programs/services offered and or performed by Contractor.
The Contractor shall follow all guidelines pertaining to registration procedures as listed in the
quarterly recreation schedule. Participants may not take part in the program unless they are listed on
the class roster or can show proof of enrollment. All participants and volunteers need to complete the
City's Waiver of Liability form prior to taking part in the program. If applicable,contractors who are
responsible for supervising minors must remain with the class until a parent of legal guardian has
arrived and all minors are released to them.
In the event of an injury occurring to a participant, the Contractor will notify the City within 1 hour
and complete an Incident Report in the form approved by the City. The Incident Report must be
submitted to the City within 24 hours of the injury occurring.
Exhibit B
Insurance Requirements for Recreation Contracts
As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance
for the duration of the contract against claims arising from or in connection with Contractor, its agents,
representatives,employees or subcontractors Services under this Agreement.
Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as:
1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an
occurrence" basis, including property damage, bodily injury and personal & advertising injury with
limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply
separately to this project/location(CG 25 03 or 25 04)or be twice the required occurrence limit.
2 Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos,
Code 8(hired) and 9(non-owned), with limits no less than $1,000,000 per accident for bodily injury and
property damage.
Required if automobile is used to perform work under this contract.
Otherwise, proof of Contractor's personal auto insurance with limits required by state law
sc ces. Contractor shall not transport or use its personal vehicle to transport participants or
perform work under this contract.
3. Workers' Compensation: As required by the State of California, with Statutory and Employer's
Liability Insurance limits of no less than$1,000,000 per accident for bodily injury or disease.
C/Required if Contractor has employees.
If no employees,Contractor must sign Affidavit of No Employees.
4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/services involving
minors, (i.e., after school activities, recreational programs, athletics, study/training events and
transportation of minors). Coverage may be included under General Liability or be obtained in a separate
policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per
occurrence. If a general aggregate limit applies, it must apply separately to this contract or be twice the
required occurrence limit.
dRequired if Contract involves services to children.
Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance.
Self-Insured Retentions: Self-insured retentions must be approved by City. City may require Contractor to
provide proof of ability to pay losses and related investigations, claim administration, and defense
expenses within the retention. The policy language must provide, or be endorsed to provide, that the self-
insured retention may be satisfied by either the named insured or City.
Acceptability of Insurers:Insurance must be issued by insurers acceptable to City and licensed to do business
in the State of California,with an A.M. Best's financial strength rating of"A"or better and a financial size
rating of"VII"or better.
OTHER INSURANCE PROVISIONS: The CGL policy must contain, or be endorsed to contain, the
following provisions:
1. The City, its City Council, boards and commissions, officers, officials, employees, agents, servants
and volunteers are to be covered as additional insureds with respect to liability arising out of work or
Exh.B Insurance for Recreation Contracts Updated 3-26-18
I
operations performed by or on behalf of the Contractor including materials, parts or equipment
furnished in connection with such work or operations.
2. Contractor's insurance shall be primary insurance coverage at least as broad as ISO CG 20 0104
13 as respects the City,its officers,officials,employees,agents,and volunteers.
3. The Insurance Company agrees to waive all rights of subrogation against the City,its elected or
appointed officers,officials,agents,and employees for losses paid under the terms of any policy
which arise from work performed by Contractor for City.This provision also applies to the
Contractor's Workers' Compensation policy.
4. Each insurance policy required by this contract shall provide that coverage shall not be canceled,
except with notice to the City.
Primary Coverage: The Additional Insured coverage under Contractor's policy shall be primary non-
contributory and at least as broad as ISO CG 20 01 04 13 as respects the City and all the
insureds/indemnitees. If the limits of insurance required are satisfied in part by Umbrella/Excess Insurance,
the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall
also apply on a"primary and non-contributory" basis for the benefit of the Additional Insureds before City's
own insurance is triggered.
Notice of Cancellation:Each insurance policy shall provide that coverage shall not be canceled or allowed to
expire without written notice to City 30 days in advance or 10 days in advance if due to non-payment of
premiums. Such notice must be sent to City via email or certified mail to the attention of the City Manager.
Waiver of Subrogation:Contractor grants City a waiver of any right to subrogation which any insurer of said
Contractor may acquire against City by virtue of payment of any loss under such insurance. Contractor will
obtain any endorsement that may be necessary to effect this waiver of subrogation, but this provision applies
regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer.
Verification of Coverage:Contractor shall furnish the City with original certificates and amendatory
endorsements effecting coverage required by this clause. All certificates and endorsements are to be received
and approved by the City before work commences.The City reserves the right to require complete,certified
copies of all required insurance policies,including endorsements affecting the coverage required by these
specifications,at any time. At a minimum Contractor must provide acceptable copies of the policy
declarations and endorsement page verifying the required insurance coverages.
Homeowner's Insurance:Contractor's homeowner's liability insurance may provide coverage sufficient to
meet these requirements. Contractor should provide these requirements to his or her agent to confirm and
provide verification to City.
Special Events Coverage:Insurers may provide special events coverage for a reduced fee,or City may be
able to offer this coverage. Contractor should contact the City Manager's Office for information or assistance.
Special Risks or Circumstances:City reserves the right to modify these requirements based on the nature of
the risk,prior experience,insurer,coverage,or other special circumstances.
Exh.B Insurance for Recreation Contracts Updated 3-26-18
2
EXHIBIT D
Contractor's Mandated Reporter Declaration
The undersigned does hereby certify that:
1. I am a representative of LISA MOLARO; that I am familiar with the facts herein and am
authorized and qualified to execute this declaration.
2. I declare that LISA MOLARO 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. 1 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.
LISA MOLARO
By: LISA O
Title: INSTRUCTOR
Date: 0 l
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.:
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:
Lisa Molaro TYPE: Arts And Crafts(Various)
LOCATION: Wilson Park Ceramic Center,19784 Wintergreen Drive.Cupertino,CA 95014
Liquor Liability Yes No
Liquor Liability after 12 am ends before 2 am
This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy
period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless
amended as described in Special Conditions.
INSURANCE CARRIER:Evanston Insurance Company
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: January 01,2018 EXPIRATION: January 01,2019
COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE
Aggregate Limit 2,000,000
Products&Completed Operations 1,000,000 SPECIAL CONDITIONS:
Personal&Advertising Injury 1,000,000 The following endorsements attached to
Each Occurrence Limit 1,000,000 the Master Policy do not apply to this
Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance:
Medical Payments(Any One Person) 5,000 MEGL1643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
1,000,00053,000,000
2,000,00052,000,000
Property Damage(If purchased)
No Property Damage Coverage
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
City of Cupertino, Its City Council, Boards and
Commissions, Officers, Officials, Employees,
Agents, Servants, Volunteers and Consultants
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy
provisions.
AUTHORIZED REPRESENTATIVE:
Q
DATE ISSUED: 01/18/2018
POLICY NUMBER: SEP41026 COMMERCIAL GENERAL LIABILITY
CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of Cupertino, Its City Council, Boards and Commissions, Officers,
Officials, Employees, Agents, Servants, Volunteers and Consultants
For Certificate No.:
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following is added to
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to liability for "bodily injury", "property If coverage provided to the additional insured is
damage" or "personal and advertising injury" required by a contract or agreement, the most we
caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the
omissions or the acts or omissions of those acting amount of insurance:
on your behalf:
1. Required by the contract or agreement; or1. In the performance of your ongoing operations;
or 2. Available under the applicable Limits of
2. In connection with your premises owned by or
Insurance shown in the Declarations;
rented to you. whichever is less.
However: This endorsement shall not increase the
1. The insurance afforded to such additional
applicable Limits of Insurance shown in the
Declarations.
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 26 04 13 Insurance Services Office, Inc., 2012 Page 1 of 1
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: SEP41026
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name Of Person Or Organization: City of Cupertino, Its City Council, Boards and Commissions,
Officers, Officials, Employees,Agents, Servants, and Volunteers
Additional Premium: $ 150.00
The following is added to Condition S. Transfer Of Rights Of Recovery Against Others To Us under Section IV —
Commercial General Liability Conditions:
We waive any right of recovery we may have against the person or organization shown in the Schedule of this
endorsement with respect to written contracts that exist between you and such person or organization, provided you have
agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule of
this endorsement.
All other terms and conditions remain unchanged.
MEGL 024105 16 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1
with its permission.
csaa Insurance Exchange Automobile PolicyDeclarations
P.O.Box 22221
Insurance 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 1
1.Name and Address of Insured
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LISA M MOLARO Numbersince
Z Named Insured,but not prior to the time applied
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Alternate Address Occupation Ahernate Number Telephone Number
Engineer/Scientist 650)906-1171
Item Make Model}r Body Type Vehicle identification No. Name
LA 1
vehicles
Coverage Liabr!ity Limns item Rem 2
Each Person Each Occurrence Deductible Premium Deductible Premium Deductible Premium Deductible Premium
Bodily Injury 500,000 500,000 186 172
Medical Payments 10,000 36 26
Uninsured Motorists 300,000 500,000 40 37
Property Damage 300,000 238 299
Comprehensive Actual Cash Value Less Deductible 250 $82 250 $92
Full Comprehensive Safety Glass Endorsement
l$0 deductible)-----•-••-----•------------------•---................... NO COV NO COV; E E
Collision Actual Cash Value Less Deductible 500 $509 500 $511
Enhanced Transportation Expense
25 per day/$750 aggregate 28 28
II Risks Actual Cash Value Less Deductible No Coverage No Coverage
Vehicle Loan/Lease Protection Endorsement No Coverage No Coverage
New Car Added Protection Endorsement No Coverage No Coverage
Original Equipment Manufacturer Parts(OEM)Endorsement No Coverage No Coverage
Ride-sharing Coverage Endorsement No Coverage No Coverage
TOTAL PREMIUM PER VEHICLE 1,119 1,165
Automobile Death Benefits $15,000 per deceased insured person Pr$9m
Premium Summary
This is not a bill.
CA Surcharge: $0
CA Special Fraud Assessment Fee:$3.52
Total Premium: 2,296.52
Total Premium shown is for the Member AdvantageTm Program.
EXCLUSIONS
There is no coverage provided by this Policy while the following individual(s)operate a motor vehicle:
None
Schedule of Changes
HW
Q
Z
Q
V
55 1500 12 15
09-22-2017
051460210 Continued on back)
Item Rated Driver Dni,SafetyRecord Yrs Drw Exp Prior Ann Miles Future Ann Miles Veh Garage Zip Vehicle Usage Gender Marital
1
for explanation
of codes.w
CW
C
N
z Discounts:
Mature Driver:None.Multi Car:Item(s) 1,2.
yGood Driver:Item(s) 1, 2. New Driver:None.
o Multi Policy home:Item(s) 1,2. Good Student:None.
You may qualify for other products
W
W
and discounts. For more info call
your Insurance Agent
a
N Mark Fordyce
O 408)725-4333
J
IMPORTANT NOTICE:THIS IS A PART OF YOUR DECLARATIONS
The insurance afforded is only with respect to such of the preceding coverages as are indicated by specific premium charge or charges.The
limit of the Exchange's liability under each such coverage shall be as stated herein,subject to all the terms of the policy.The purpose for
which the automobile is to be used is pleasure or business,subject to the exclusions in the policy, including the exclusion for wholesale
and retail delivery.
RENEWAL CERTIFICATE -Extends this policy for the period shown under Policy Period upon payment of the premium.
AMENDED DECLARATIONS-In consideration of the premium adjustment indicated herein this policy is hereby amended only with respect
to such changes as are indicated in the schedule of changes.The limit of the Exchange's liability under such amended coverage shall be as
stated herein.
LOSS PAYEE(S)-Any loss under Physical Damage coverages is payable as interest may appear to the named insured and the Loss Payee in
i accordance with the loss payable agreement.
RATING INFORMATION DISCLOSURE EXPLANATION
From Discounts/Messages Section on Previous Page)
ITEM (ITEM NUMBER): Item number is the number assigned to the vehicle shown on the Declarations.
RATED DRIVER:The driver assigned to a vehicle whose attributes(e.g.,years driving experience, driving safety record, gender, and marital
status)are used to develop the premium.
DRIV SAFETY RECORD(DRIVING SAFETY RECORD):The total number of points assessed the driver for "principally at fault chargeable
accidents" with or without injury and/or vehicle code violation convictions(tickets).A "principally at fault chargeable accident" occurs
when the driver of a vehicle is at least 51% at fault for an accident and the total monetary damages(whether paid or not)in the accident
exceed:
750 or the accident resulted in death for losses occurring prior to 12/11/11
1,000 or the accident resulted in death for losses occurring 12/11/2011 or after
Additional information on the number and types of incidents can be provided on request. Carriers use different point count systems for
rating purposes.The number of points shown on your declarations would not necessarily match the number of points assigned by
another carrier.
YRS DRIV EXP(YEARS DRIVING EXPERIENCE): The number of years a driver has been licensed to drive a motor vehicle anywhere in the
world. However, a driver must have at least 18 months current driving experience in the United States, U.S.Territories, or Canada, before
foreign country driving experience can be counted.
PRIOR ANN MILES(PRIOR ANNUAL MILES DRIVEN):The estimated number of total miles a vehicle was driven during the year just past.
FUTURE ANN MILES(FUTURE ANNUAL MILES DRIVEN):The estimated number of total miles a vehicle will be driven in the coming year.
VEH GARAGE ZIP(VEHICLE GARAGED ZIP CODE):The ZIP code of the location where the vehicle is garaged.
VEHICLE USAGE:Vehicles are assigned to one of five usage designations: Business Use, Work Commute, Farm Use, Farm Business Use or
Pleasure.
GENDER: "M" stands for Male and "F" stands for Female.
MARITAL(MARITAL STATUS): "M" stands for Married, and "S" stands for Single.
DISCOUNTS:A reduced rate applies for each Discount listed.
551500 1215
09-22-2017
051470210
CERTHOLDER COPY
NA
STATE
P.O. BOX 8192, PLEASANTON, CA 94588
INSURANCE
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 07-05-2018 GROUP:
POLICY NUMBER:
CERTIFICATE ID: 1
CERTIFICATE EXPIRES: 06-29-2019
06-29-2018/06-29-2019
CITY OF CUPERTINO PARKS AND NA
RECREATION
10185 N STELLING RD
CUPERTINO CA 95014-5732
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
MOLARO, LISA DBA: MUDNSTIX NA
ISS,CSj
REv.7-2014)
PRINTED : 07-05-2018
ARC H r
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
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(&beazley.com
860)677 3765(phone)
860)679 0247(fax)
Retroactive Date:
I"July 2018
Pending or Prior Litigation Date:
I"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: 5`h 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.