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Director of Parks and Recreation Jun 5, 2020 Christine Hanel L9L&L9L << < :< L L GGGGGGGGGGGGGGGGGGGGGGGGGGGGGL L>L L ,')+ %&L +0L++&)%0L :< L L GGGGGGGGGGGGGGGGGGGGGGGGGGGGGL L L +0L#)"L << +LGGGGGGGGGGGGGGGGGGGGGGGGL &%+)+I%,$)L$&,%+@L<53?222L&)L42J43?L<53?222L&)L43J44?L<53?222L&)L44J45L &,%+L &>@L7:2J84J835J922J924L L Heather M. Minner Jun 5, 2020 Updated 4/15/20 EXHIBIT A SCOPE OF WORK, PERFORMANCE AND PAYMENT SCHEDULES The CONTRACTOR will provide YOUTH/TEEN CLASSES/CAMPS in, but not limited to, the following: LET’S READ, SAT PREP, BIOLOGY CAMP, CHEMISTRY CAMP, PHYSICAL SCIENCE CAMP, GEOMETRY CAMP Location and Time of CONTRACTOR Services: Refer to the Recreation Schedule dated SUMMER 2020 - SUMMER 2023 for agreed upon dates, times, and locations of a class, camp, activity, program, or service (“class”). The City, at its sole discretion, may change the agreed dates, times and locations of a class, or may cancel a class. Compensation for CONTRACTOR Services: Contractor shall be compensated for services performed pursuant to this Agreement. For a class taught in person, 70% of resident fee minus $10 per participant based on final roster. City and Contractor may mutually agree for Contractor to teach a class online rather than in person, provided that City and Contractor reach agreement for compensation for that online class. Compensation for that online class shall be specified in writing in a separate side agreement before online instruction for a class begins. The total compensation to the Contractor shall not exceed $31,000 FOR FY 20-21, $31,000 FOR FY21-22, $31,000 FOR FY 22-23. Eligible Participant Minimum and Maximums for CONTRACTOR Services: Minimum: 4 Maximum: 12 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__________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ Updated 4/15/20 ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ Performance of CONTRACTOR Services Class Cancellation Contractor will only receive compensation for a class that is performed. If performance of a class is cancelled by the City or Contractor before instruction begins, Contactor will not receive compensation for the class. If the City or Contractor cancels performance of certain meetings of a class, Contractor will only receive compensation for those meetings of the class that are performed. In the case Contractor unilaterally cancels performance of a class without City approval, City reserves the right to immediately and without notice cancel the remainder of classes offered and or performed by Contractor. COVID-19 Health Order Compliance Contractor acknowledges that its duty to comply with Laws, as stated in Section 13 of the Agreement, includes compliance by Contractor with the restrictions on travel and the Social Distancing Requirements set forth in Section 13.k of the health order issued by the County of Santa Clara Public Health Department on March 31, 2020, in response to the COVID-19 pandemic, and any subsequent amendments or superseding orders thereto (the “Health Order”), and any other local, state, or federal laws or policies that have been or may be enacted in response to the COVID-19 pandemic (collectively, “Health Laws”). Contractor shall comply with these restrictions on travel and Social Distancing Requirements when preforming work under this Agreement. If this Agreement specifies work that cannot be performed in compliance with the Health Order or Health Laws, Contractor shall refrain from conducting the work and immediately inform the City. Contractor shall likewise comply with any City protocols designed to help prevent the spread of COVID-19. Contractor acknowledges that the need to comply with the Health Order and Health Laws may result in the City canceling performance of any class or meetings of a class referenced in this Agreement. Registration, Enrollment, and Supervision 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. Injury of a Class Participant 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. Exh. B Insurance for Recreation Contracts Updated May 2020 1 As required by the Agreement, Contractor shall procure prior to commencement of Services and maintain the following insurance for the duration of the Agreement 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. a) It shall be a requirement that any available insurance proceeds broader than or in excess of the specified minimum insurance coverage requirements and/or limits shall be made available to the Additional Insured and shall be (i) the minimum coverage/limits specified in this agreement; or (ii) the broader coverage and maximum limits of coverage of any insurance policy, whichever is greater. b) Additional Insured coverage under Consultant's policy shall be "primary and non-contributory," will not seek contribution from City’s insurance/self-insurance, and shall be at least as broad as ISO Form CG 20 01 (04/13). c) The limits of insurance required may be satisfied by a combination of primary and umbrella or excess insurance, provided each policy complies with the requirements set forth in this Contract. Any umbrella or excess insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a primary basis for the benefit of City before the City’s own insurance or self-insurance shall be called upon to protect City as a named insured. law 2. Automobile Liability (select one): ¼ 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.) ¼ Proof of Contractor’s personal auto insurance with limits required by state law. (Contractor shall not transport or use its personal vehicle to transport participants or perform work under this contract.) ¼ Automobile insurance is waived. (Contractor shall never use a vehicle while working under this contract, other than to commute to and from the work site. Contractor shall not use a vehicle to travel between City sites, between classes, etc.) 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. ¼ Required if Contractor has employees. ¼ 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. ¼ Required if Contract involves services to children. Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance. Exhibit B Insurance Requirements for Recreation Contracts Exh. B Insurance for Recreation Contracts Updated May 2020 2 OTHER INSURANCE PROVISIONS The aforementioned insurance shall be endorsed and have all the following conditions and provisions: Additional Insured Status The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers (“Additional Insureds”) are to be covered as additional insureds on Consultant’s CGL and automobile liability policies. General Liability coverage can be provided in the form of an endorsement to Consultant’s insurance (at least as broad as ISO Form CG 20 10 (11/ 85) or both CG 20 10 and CG 20 37 forms, if later editions are used). Primary Coverage Coverage afforded to City/Additional Insureds shall be primary insurance. Any insurance or self-insurance maintained by City, its officers, officials, employees, or volunteers shall be excess of Consultant’s insurance and shall not contribute to it. Notice of Cancellation Each insurance policy shall state that coverage shall not be canceled or allowed to expire, except with written notice to City 30 days in advance or 10 days in advance if due to non-payment of premiums. Waiver of Subrogation Consultant waives any right to subrogation against City/Additional Insureds for recovery of damages to the extent said losses are covered by the insurance policies required herein. Specifically, the Workers’ Compensation policy shall be endorsed with a waiver of subrogation in favor of City for all work performed by Consultant, its employees, agents and subconsultants. This provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. Deductibles and Self-Insured Retentions Any deductible or self-insured retention must be declared to and approved by the City. At City’s option, either: the insurer must reduce or eliminate the deductible or self-insured retentions as respects the City/Additional Insureds; or Consultant must show proof of ability to pay losses and costs related investigations, claim administration and defense expenses. The policy shall provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the insured or the City. Acceptability of Insurers Insurers must be licensed to do business in California with an A.M. Best Rating of A-VII, or better. Verification of Coverage Consultant must furnish acceptable insurance certificates and mandat ory endorsements (or copies of the policies effecting the coverage required by this Contract), and a copy of the Declarations and Endorsement Page of the CGL policy listing all policy endorsements prior to commencement of the Contract. City retains the right to demand verification of compliance at any time during the Contract term. Subconsultants Consultant shall require and verify that all subconsultants maintain insurance that meet the requirements of this Contract, including naming the City as an additional insured on subconsultant’s insurance policies. Higher Insurance Limits If Consultant maintains broader coverage and/or higher limits than the minimums shown above, City shall be entitled to coverage for the higher insurance limits maintained by Consultant. Adequacy of Coverage City reserves the right to modify these insurance requirements/coverages based on the nature of the risk, prior experience, insurer or other special circumstances, with not less than ninety (90) days prior written notice. 1223215.2 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: - CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with Apex Insurance Services P. O. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: TYPE: DATE(S): LOCATION: *Liquor Liability Yes No **Liquor Liability after 12 am ends before 2 am 7KLVLVWRFHUWLI\WKDWWKHLQVXUDQFHSROLF\OLVWHGEHORZKDVEHHQLVVXHGWRWKHDERYHLQVXUHGQDPHGHYHQWKROGHUIRUWKHSROLF\ SHULRGLQGLFDWHG7KHLQVXUDQFHGHVFULEHGKHUHLQLVVXEMHFWWRDOOWKHWHUPVH[FOXVLRQVDQGFRQGLWLRQVRIVXFKSROLF\LHVXQOHVV DPHQGHGDVGHVFULEHGLQ6SHFLDO&RQGLWLRQV INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: MASTER POLICY DATES:EFFECTIVE:EXPIRATION: COMMERCIAL GENERAL LIABILITY General Aggregate Limit Products & Completed Operations Personal & Advertising Injury Each Occurrence Limit 'DPDJH7R3UHPLVHV5HQWHG7R<RX$Q\2QH3UHPLVHV Medical Payments (Any One Person) Liquor Liability (If purchased) Optional Limits Purchased $1,000,000/$3,000,000 $2,000,000/$2,000,000 Property Damage (If purchased) $ 2,000,000 1,000,000 1,000,000 1,000,000 100,000 5,000 1,000,000 OCCURRENCE FORM DEDUCTIBLE: NONE 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 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: DATE ISSUED: 41&$*"-$0/%*5*0/4 5IFGPMMPXJOHFOEPSTFNFOUTBUUBDIFEUP UIF.BTUFS1PMJDZEPOPUBQQMZUPUIJT $FSUJGJDBUF0G*OTVSBODF .&(- January 01, 2020 Academic Monta Vista Recreation Center, 22601 Voss Ave, Cupertino, CA 95014 City of Cupertino City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants ● No Property Damage Coverage 01/14/2020 Natasha Austin 100 1/14/2020 - 12/31/2020 637 P41030 January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³QRQDGPLWWHG´RU³VXUSOXVOLQHV´LQVXUHUV 7KHLQVXUHULVQRWVXEMHFWWRWKHILQDQFLDOVROYHQF\UHJXODWLRQDQG HQIRUFHPHQWWKDWDSSO\WR&DOLIRUQLDOLFHQVHGLQVXUHUV 7KHLQVXUHUGRHVQRWSDUWLFLSDWHLQDQ\RIWKHLQVXUDQFHJXDUDQWHH IXQGVFUHDWHGE\&DOLIRUQLDODZ7KHUHIRUHWKHVHIXQGVZLOOQRWSD\ \RXUFODLPVRUSURWHFW\RXUDVVHWVLIWKHLQVXUHUEHFRPHVLQVRO YHQW DQGLVXQDEOHWRPDNHSD\PHQWVDVSURPLVHG 7KHLQVXUHUVKRXOGEHOLFHQVHGHLWKHUDVDIRUHLJQLQVXUHULQDQRWKHU VWDWHLQWKH8QLWHG6WDWHVRUDVDQRQ8QLWHG6WDWHVDOLHQLQVXUHU<RX VKRXOGDVNTXHVWLRQVRI\RXULQVXUDQFHDJHQWEURNHURU³VXUSOXV OLQH´EURNHURUFRQWDFWWKH&DOLIRUQLD'HSDUWPHQWRI,QVXUDQFHDWWKH WROOIUHHQXPEHURULQWHUQHWZHEVLWH ZZZLQVXUDQFHFDJRY$VNZKHWKHURUQRWWKHLQVXUHULVOLFHQVHGDVD IRUHLJQRUQRQ8QLWHG6WDWHVDOLHQLQVXUHUDQGIRUDGGLWLRQDO LQIRUPDWLRQDERXWWKHLQVXUHU<RXPD\DOVRYLVLWWKH1$,&¶VLQWHUQHW ZHEVLWHDWZZZQDLFRUJ7KH1$,&±WKH1DWLRQDO$VVRFLDWLRQRI ,QVXUDQFH&RPPLVVLRQHUV±LVWKHUHJXODWRU\VXSSRUWRUJDQL]DWLRQ FUHDWHGDQGJRYHUQHGE\WKHFKLHILQVXUDQFHUHJXODWRUVLQWKH8QLWHG 6WDWHV )RUHLJQLQVXUHUVVKRXOGEHOLFHQVHGE\DVWDWHLQWKH8QLWHG6WDWHV DQG\RXPD\FRQWDFWWKDWVWDWH¶VGHSDUWPHQWRILQVXUDQFHWRREWDLQ 03,/&$3DJHRI PRUHLQIRUPDWLRQDERXWWKDWLQVXUHU<RXFDQILQGDOLQNWRHDFKVWDWH IURPWKLV1$,&LQWHUQHWZHEVLWHKWWSVQDLFRUJVWDWHBZHEBPDSKWP )RUQRQ8QLWHG6WDWHVDOLHQLQVXUHUVWKHLQVXUHUVKRXOGEH OLFHQVHGE\DFRXQWU\RXWVLGHRIWKH8QLWHG6WDWHVDQGVKRXOGEHRQ WKH1$,&¶V,QWHUQDWLRQDO,QVXUHUV'HSDUWPHQW,,'OLVWLQJRIDSSURYHG QRQDGPLWWHGQRQ8QLWHG6WDWHVLQVXUHUV$VN\RXUDJHQWEURNHURU ³VXUSOXVOLQH´EURNHUWRREWDLQPRUHLQIRUPDWLRQDERXWWKDWLQVXUHU &DOLIRUQLDPDLQWDLQVD³/LVWRI$SSURYHG6XUSOXV/LQH,QVXUHUV /$6/,´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¶VIHHFKDUJHGIRUWKLV LQVXUDQFHZLOOEHUHWXUQHGWR\RX ROBERT D AUSTIN NATASHA AUSTIN 1. Name and Address of Insured POLICY INFORMATION (Continued on back ) Automobile Policy Declarations Please keep with your policy. See Important Notice on reverse. For questions or changes call: (800) 922-8228 Page 1 of 1 Alternate Address Occupation Alternate Number Telephone Number Engineer/Scientist (408) 446-0506 Item Make Model Yr Body Type Vehicle Identification No. Drivers do not necessarily correspond to principally operated vehicles. SUV 5J6RM3H97GL021303 NATASHA KATHERINEDRIVERSVEHICLESDeclarations Type Process Date Policy Number Insured Since Your Policy Period From 12:01 A.M. Standard Time at the address of the Named Insured, but not prior to the time applied for or, if this is a replacement declarations, not prior to the time coverage change was requested. To 12:01 A.M. Standard Time at the address of the Named Insured. Renewal Certificate 07- 2019 CAAS100181912 1981 08-21-2019 08-21-2020 Coverage Liability Limits Item 1 Item 2 Each Person Each Occurrence Deductible Premium Deductible Premium Deductible Premium Deductible Premium Bodily Injury 100,000 300,000 $135 $117 Medical Payments No Coverage Uninsured Motorists 100,000 300,000 $32 $31 Property Damage 100,000 $215 $294 Comprehensive Full Comprehensive ($0 deductible) Actual Cash Value Less Deductible Safety Glass Endorsement 100 NO COV $37 100 NO COV $107 Collision Actual Cash Value Less Deductible 500 $241 500 $493 EnhancedTransportationExpense $25 per day/$750aggregate $28 $28 All Risks Actual Cash Value Less Deductible Vehicle Loan/Lease Protection Endorsement New Car Added Protection Endorsement Original Equipment Manufacturer Parts (OEM) Endorsement Ride-sharing Coverage Endorsement TOTAL PREMIUM PER VEHICLE Ø $688 $1,070 * Automobile Death Benefits $15,000 per deceased insured person Premium $6 Premium Summary This is not a bill. CA Surcharge: $0 CA Special Fraud Assessment Fee: $3.52 Total Premium: $1,767.52 Total Premiumshown is for the MemberAdvantage TM Program. EXCLUSIONS There is no coverage provided by this Policy while the following individual(s) operate a motor vehicle: None No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage Schedule of Changes CHANGESCSAA Insurance Exchange P.O.Box 22221 Oakland, CA 94623-2221 55 1500 07 19 07-17-2019 07980 0210 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. Item Rated Driver Driv Safety Record Yrs Driv Exp Prior Ann Miles Future Ann Miles Veh Garage Zip Vehicle Usage Marital See final page for explanation of codes. 1 ROBERT AUSTIN 0 Pt 42 8,310Mi 8,310Mi Commute M Discounts: Mature Driver: None. Good Driver: Item(s) 1, 2. Multi Policy condo: Item(s) 1, 2. Multi Car: Item(s) 1, 2. New Driver: None. Good Student: None. You may qualify for other products and discounts. For more info call your Insurance Agent Item 1 Kevin Lee Edelberg (408) 725-4316 LOSS PAYEE(S) DISCOUNTS/MESSAGES 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. 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. MARITAL (MARITAL STATUS): “M” stands for Married, and “S” stands for Single. DISCOUNTS: A reduced rate applies for each Discount listed. 55 1500 07 19 07-17-2019 07981 0210 CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE Form: SML Safeguard Wording - 623AFB00213 Policy Number: Renewal of: 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: 1st July 2019 To: 1st 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 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: 1st July 2018 Pending or Prior Litigation Date: 1st 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: 0C66724 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) Natasha Austin Contract Final Audit Report 2020-06-06 Created:2020-06-03 By:Kevin Khuu (KevinK@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAHh82YdDHUwkJNCyzZ4_x2LGVjoW9BQJc "Natasha Austin Contract" History Document created by Kevin Khuu (KevinK@cupertino.org) 2020-06-03 - 9:44:48 PM GMT- IP address: 73.158.53.147 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2020-06-03 - 9:48:23 PM GMT Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2020-06-03 - 11:05:48 PM GMT - Time Source: server- IP address: 24.23.184.82 Document emailed to Heather M. Minner (minner@smwlaw.com) for signature 2020-06-03 - 11:05:51 PM GMT Email viewed by Heather M. Minner (minner@smwlaw.com) 2020-06-05 - 9:20:25 PM GMT- IP address: 45.41.142.96 Document e-signed by Heather M. Minner (minner@smwlaw.com) Signature Date: 2020-06-05 - 9:20:59 PM GMT - Time Source: server- IP address: 52.39.49.65 Document emailed to Christine Hanel (christineh@cupertino.org) for signature 2020-06-05 - 9:21:03 PM GMT Email viewed by Christine Hanel (christineh@cupertino.org) 2020-06-06 - 1:00:50 AM GMT- IP address: 104.47.44.254 Document e-signed by Christine Hanel (christineh@cupertino.org) Signature Date: 2020-06-06 - 1:01:35 AM GMT - Time Source: server- IP address: 73.241.47.109 Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature 2020-06-06 - 1:01:38 AM GMT Email viewed by Kirsten Squarcia (kirstens@cupertino.org) 2020-06-06 - 1:06:34 AM GMT- IP address: 148.64.105.190 Document e-signed by Kirsten Squarcia (kirstens@cupertino.org) Signature Date: 2020-06-06 - 2:27:36 AM GMT - Time Source: server- IP address: 148.64.105.190 Signed document emailed to cyrahc@cupertino.org, Araceli Alejandre (aracelia@cupertino.org), Christine Hanel (christineh@cupertino.org), Heather M. Minner (minner@smwlaw.com), and 2 more 2020-06-06 - 2:27:36 AM GMT