19-001 Savita Adiga CITY OF
No.
12 FY2019-20
CUPERTINO
RECREATION SERVICES AGREEMENT
1. Parties. This contract is made and entered into as of 11/11/2019 ("Effective Date"), by
and between the City of Cupertino, a municipal corporation("City"), and with SAVITA ADIGA,
("Contractor"), a FITNESS INSTRUCTOR for
BOMBAY JAM.
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$2000.00("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, 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 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
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:/Iwww.cdc.gov/headsul2/index.htmD.
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: Colleen Ferris Name: SAVITA ADIGA
Position: Recreation Coordinator Position: Fitness instructor
Contact: colleenf@cupertino.org 408-777-3160 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 j
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:
Colleen Ferris SAVITA ADIGA
Email: colleenf@cupertino.org Email:
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
SAVITA ADIG A Municipal Corporation
By .�v�C�� By6
Name SAVITA ADIGA Name 1� 1,-•IgVV��
Title Fitness instructor Title
Date Date C\
Tax I.D. No.:
APPROVED AS TO FORM: ATTEST:
HEATHER M. MINNER GRACE SCRIWDT
Cupertino City Attorney City Clerk
ContractlEncumbered Amount:$2,000.00
Account No.:570 63 621 700 702
Recreation Services Agreement/Rev. 3-27-2018
Page 6 of 6
EXHIBIT A
SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide FITNESS INSTRUCTOR in,but not limited to,the following:
BOMBAY JAM
Location and Time of CONTRACTOR Services:
Refer to the MONTHLY FITNESS CLASS SCHEDULE 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: $35/class. The total compensation to the Contractor shall not exceed
$2,000.
Eligible Participant Minimum and Maximums for CONTRACTOR Services:
Minimum: 10
Maximum: 50
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"):
self
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
j
As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance j
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.
X Otherwise, proof of Contractor's personal auto insurance with limits required by state law
suffices. 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.
❑ Required if Contractor has employees.
X 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.
Required 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
1
operations performed by or on behalf of the Contractor including materials, parts or equipment
famished 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, G
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 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 Savita Adiga.
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 18 day of September, 2019, at Cupertino, California.
N - i
PRINT NAME
SlIGNATURE
EXHIBIT D
Contractor's Mandated Reporter Declaration
The undersigned does hereby certify that:
1. I am a representative of SAVITA ADIGA; that I am familiar with the facts herein and am
authorized and qualified to execute this declaration.
2. I declare that SAVITA ADIGA 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"):
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.
SAVITA ADIGA
A6,1ii
By: AVITA ADIGA
Title: FITNESS INSTRUCTOR
Date:
I
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The Medical Protective Company
A STOCK INSURANCE COMPANY
5814 Reed Road,Fort Wayne,Indiana 46835
Strength.Defense,Solutions.Since 1899.
MULTI-SPECIALTY HEALTHCARE PROFESSIONAL-CERTIFICATE
Policy 09/22/2019 To:09/2212020
Period: at I :.I a.m.Standard lime at the address of the First Named Insured. Certificate Number:
Item 1(a)Named Insured: Student Non-Insured acting in the capacity of an Administrative
First Named Insured
Professional Services Specialty:Fitness Professional(Group Fitness Instructor)
Classification:40
First Named Insured Address: Iteml(b)Additional Insureds:
Savita Adiga
New Business X Renewal Business
COVERAGES: POLICY TYPE LIMITS OF LIABILITY
Occurrence standard Convertible RETROACTIVE DATE Per Claim
Claims Made Claims Made / Aggregate
PROFESSIONAL LIABILITY X
A.Professional Liability(PL)& $1,000,000 $3,000,000
B.Good Samaritan Acts
C.Assault Upon You $25,000 $25,000
D.First Aid $15,000 $15,000
E.Medical Payments $25,000 $100,000
F.Deposition Fees $10,000 $10,000
Administrative Hearing Expense $25,000 $100,000
Sexual Misconduct Expense $25,000 $25,000
Loss of Earnings $2,500 $35,000
HIPAA Proceeding Expense $25,000 $25,000
WORKPLACE LIABILITY X
A.Healthcare Professional Premises
Liability& Included in Professional Liability Limit
B.Personal Injury Liability
Work lace VabifitV does not appiv it the General Liability Insurinq Areement is made art of vour covers e.
EMPLOYMENT PRACTICES LIABILITY
CYBER LIABILITY
Network Security&Privacy
Regulatory Fines&Penalties
Patient Notification&Credit
Monitoring Costs
Data Recovery Costs
General C ber Annual Aggregate
BILLING ERRORS&OMMISSIONS
COMMERCIAL GENERAL LIABILITY
Each Occurrence Limit
Damages to Premises Rented
to an Insured Business
Personal&Advertising Injury
General Aggregate Limit
Product Completed Operations Aggregate
Hired and Non—Owned Auto
General LiabilftV does not app1V if the Workplace Liability Insuring Areement is made Part o! our covers e.
FORMS&ENDORSEMENTS: 18511 18519 18522 18528 18550 18709 Master Policy Number:
19510
RISK PURCHASING GROUP NOTICE: An insurance policy purchased from The Medical IN WITNESS WHEREOF,The Medical Protective Company has caused
Protective Company through a risk purchasing group may not be subject to all state insurance laws and this policy to be signed by its President and Corporate Secretary(and
regulations.No claim against a risk purchasing group,or its members,shall be entitled to payments from any countersigned by its duly Authorized Representative,where necessary).
state insurance insolvency guaranty fund,or similar mechanism.A purchasing group,or its members,or L�
claimants against the group or its members,may not receive any benefit from such guaranty fund,or similar � Y
mechanism for claims arising under the insurance olicies procured through the purchasing group. President
Premium:$100.00 For Service or questions,please call:
Surcharges: Program Administrator CPH&Associates, s�l�ulotaxw)
Taxes:$0.00 312.987.9823 or Toll-Free 1-800-875-1911
TOTAL: 100.00 Secretary
*THIS POLICY CONTAINS CLAIMS-MADE COVERAGE. Countersignature/Authorized Representative;
**EPLI COVERAGE CONTAINS A SEPARATE LIMIT FOR DEFENSE COSTS AND INDEMNITY
ONLY.
NOTICE **DEFENSE COSTS ARE PAID WITHIN THE DEFENSE COSTS LIMIT OF LIABILITY
LIMITS MAY CHANGE BY COVERAGE PROVISION OR ENDORSEMENT.
PLEASE READ YOUR POLICY AND ENDORSEMENTS CAREFULLY.
DISCUSS WITH YOUR INSURANCE AGENT IF NEEDED.
18004 08/13
The Medical Protective Company
A STOCK INSURANCE COMPANY
5814 Reed Road,Fort Wayne,Indiana 46835
Strength.Defense.Salutions.Since 1899.
MULTI-SPECIAL HEALTHCARE PROFESSIONAL
MASTER POLICY
ADDITIONAL INSURED ENDORSEMENT
ADD/DELETEIAMEND
First Named Insured: Savita Adiga
Effective Date: 09/22/2019
Expiration Date: 09/22/2020
Issue Date: 10/06/2019
Master Policy Number:
Certificate Number:
All effective dates are 12:01 a.m.Standard Time at the address of the First Named Insured.
In consideration of a modification of premium,if any,it is understood and agreed:
Item l(b)Additional Insured stated in your Certificate is amended as listed on the Schedule of Additional Insured Change(s)
below. y
1
All other terms and conditions of the Policy remain unchanged.
{
I
r
19068 08/13
SCHEDULE OF ADDITIONAL INSURED CHANGE(S)
ADD AFFILIATED RETRO- PREMIUM/
DELETE ITEM 1(b)ADDITIONAL ITEM I(a) ACTIVE EFFECTIVE SURCHARGE/
OR INSURED NAMED DATE DATE TAXES
AMEND INSURED (If Applicable) (If Applicable)
The City of Cupertino,Its City Council,Boards and
Commissions,Officers,Officials,Employees,
ADD Agents,Servants,and Volunteers 10/06/2019
21111 Stevens Creek Blvd
cupertino,CA 95014
19068 08/13
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
Z Declarations Amended Declarations Process 07-30-2019
i i I it I II lit lir ii I Ililllnl ill I o Type Date
RADHAKRISHNA ADIGA Q Policy Insured 2018
SAVITA ADIGA cc Number Since
} Your 06-30-2019 fGF or,if this is a replacement declarations,not
u Policy prior to the time coverage change was requested.
J Period To
0 12:01 A.M.Standard Time at the address of the
G. 03_22-2020 Named Insured.
Alternate Address Occupation Alternate Number Telephone Number
Professional
Item Make Model Yr Body Type Vehicle Identification No. Name
to 1
vehicles. CHAITANYA
____••.LiabilityLimits ------------Item 1........................Item2••_•••••___..------------Item3 Item
Coverage ------..-- ----------------- --------------------*Person Each Occurrence Deductible Premium Deductible Premium Deductible Premium Deductible Premium
Bodily Injury 500,000 500,000 $151 $454 $139 $152
.....................................................................................................
Medical Payments No Coverage No Cov&age No Coverage No Coverage No Coverage
Uninsured Motorists 500,000 500,000 $33 $120 $59 $64
Property Damage 100,000 $191 $904 $236 $262
omprehensive Actual Cash Value Less Deductible 100 $133 100 i $62 100 ? $78 100 ; $85
Full Comprehensive Safety Glass Endorsement
($0 deductib__le_) NO COV NO COVI NO COV I NO COV i
Collision Actual Cash Value Less Deductible ; $5 No Coverage 500 $463 500 $473
Enhanced Transportation Expense i
$25 per day/$750 aggregate No CoArage No Coverage $28 $28
All Risks Actual Cash Value Less Deductible No Coverage No Coverage No Coverage No Coverage
Vehicle Loan/Lease Protection Endorsement No Cov4rage No Coverage No Coverage No Coverage
1
New Car Added Protection Endorsement No Cov4rage No Coverage No Coverage No Coverage
Original Equipment Manufacturer Parts(OEM)Endorsement No Covt;rage No Coverage $54 No Coverage
I,
Ride-sharing Coverage Endorsement No Cov2rage No Coverage No Coverage No Coverage ?
TOTAL PREMIUM PER VEHICLE ➢ $513 $1,540 $1,057 $1,064
*Automobile Death Benefits $15,000 per deceased insured person PremiumPremium Summary
This is not a bill.
CA Surcharge: $0
Total Return Premium: $19.00-
Total Premium shown is for the MemberAdvantageTm Program.
EXCLUSIONS
There is no coverage provided by this Policy while the following individual(s)operate a motor vehicle:
None
Schedule of Changes
w Maintain Vehicle(s) 1
0
z
x
ss 150007 19
07-30-2019
00001
0100 (Continued on back)
Item Rated Driver Driv safety Record Yrs Driv Erp Est Ann Mi Driven Veh Garage Zip Vehicle Usage Marital
Ln 1 Undesignated 3,000 Mi 95014 Pleasure
Q 2 SPOORTHI ADIGA
29 12,000 Mi 95014 Commute M
z Discounts:
:3 Mature Driver:Item(s)1,3. Multi Car:Item(s)1,2,3,4.
Good Driver:Item(s)1,3,4. New Driver:None.
p Multi Policy home:Item(s)1,2,3,4. Good Student:Item(s)2.
You may qualify for other products
W and discounts. For more info call
� your Insurance Agent
Sunil D Parekh
o (650) 623-3235
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
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 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.
EST ANN MI DRIVEN (ESTIMATED 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.
MARITAL(MARITAL STATUS): "M" stands for Married,and "S" stands for Single.
DISCOUNTS:A reduced rate applies for each Discount listed.
55 150007 19
07_30_2019
00002
0100
ARCHF. r
INTERMEDIARIES
CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE
Form: SML Safeguard Wording- 623AFB00213
Policy Number:
Named Insured: City of Cupertino—Dept of Recreation&Community Services
Public Works Department
Principal Address: 10185 N Stelling Road, Cupertino,CA,95014
Policy Period: From: I`July 2019 To: lst July 2020
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
i
Premium:
USD 27,000 to be paid within 25 days of attachment
I
Notification pursuant to Clause IX.shall be given to:
Claims Department Beazley
30 Batterson Park Road,
Farmington,
CT 06032.
claimsgbeazle,
(860)677 3765 (phone)
(860)679 0247(fax)
Retroactive Date:
1st July 2018
Pending or Prior Litigation Date:
1't July 2018
Service of Suit:
Foley&Lardner LLP,555 California Street, Suite 1700, San Francisco,CA 94104-
Choice of Law:
New York
Conditions:
Application Dated: TBA
California Surplus Lines Notice 1-LMA9098A
California Complaints Clause—LMA9136
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
Subject to:
1)Re-signed and dated renewal application—to be dated within 30 days of inception
All subjectivities 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
Information: Employees—41 Full time+255 Part Time+70 ICs
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%Lloyd's(Information about Lloyds)