20-001 Jahara Pagadipaala___________________________________________________________________________________________________
Recreation Services Agreement/ Rev. Sept. 2019
Page 1 of 7
No. ___________
FY2020-2022
RECREATION SERVICES AGREEMENT
1. Parties. This contract is made by and between the City of Cupertino, a municipal
corporation (“City”), and JAHARA PAGADIPAALA (“Contractor”), a FITNESS INSTRUCTOR for
YOGA and is effective on the last date signed below (“Effective Date”).
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 6/30/2022 (“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. The City’s appropriate department head or the City Manager may
extend the Contract Time through a written amendment to this Agreement, provided such extension
does not include additional contract funds. Extensions requiring additional contract funds are subject
to the City’s purchasing policy.
4. Compensation. City will pay Contractor for satisfactory performance of the Services an
amount that will be based upon actual costs but that will be capped so as not to exceed $3,000.00
(“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 thirty (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 the final payment.
5. Independent Contractor.
5.1 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.
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Recreation Services Agreement/ Rev. Sept. 2019
Page 2 of 7
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, if required by the
Cupertino Municipal Code.
5.2 Contractor is solely responsible for the payment of employment taxes incurred
under this Agreement and any similar federal or state taxes. Contractor and any of
its employees, agents, and subcontractors shall not have any claim under this
Agreement or otherwise against City for seniority, vacation time, vacation pay, sick
leave, personal time off, overtime, health insurance, medical care, hospital care,
insurance benefits, social security, disability, unemployment, workers compensation
or employee benefits of any kind. Contractor shall be solely liable for and obligated
to pay directly all applicable taxes, fees, contributions, or charges applicable to
Contractor’s business including, but not limited to, federal and state income taxes.
City shall have no obligation whatsoever to pay or withhold any taxes or benefits on
behalf of Contractor. Should any court, arbitrator, or administrative authority,
including but not limited to the California Public Employees Retirement System
(PERS), the Internal Revenue Service or the State Employment Development
Division, determine that Contractor, or any of its employees, agents, or
subcontractors, is an employee for any purpose, then Contractor agrees to a
reduction in amounts payable under this Agreement, or to promptly remit to City
any payments due by the City as a result of such determination, so that the City’s
total expenses under this Agreement are not greater than they would have been had
the determination not been made.
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 as
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, to the extent requested by City, constitute City property
upon completion of the work to be performed hereunder or upon termination of this Agreement.
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 (4) years from
the date of City’s final payment.
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Recreation Services Agreement/ Rev. Sept. 2019
Page 3 of 7
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 (1) 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 and active 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. This
Section 11 shall survive termination of the Agreement.
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
Agreement.
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. Consultant 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
___________________________________________________________________________________________________
Recreation Services Agreement/ Rev. Sept. 2019
Page 4 of 7
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 fingerprints and a criminal background 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, AB 2007, 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/headsup/index.html).
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 Parks & Recreation Services Instructor Manual.
Check one (if applicable):
This contract requires services for children.
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
Parks & Recreation 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:
Name: Colleen Ferris
Position: Recreation Coordinator
Contact: colleenf@cupertino.org
For Contractor:
Name: JAHARA PAGADIPAALA
Position: Fitness instructor
Contact:
___________________________________________________________________________________________________
Recreation Services Agreement/ Rev. Sept. 2019
Page 5 of 7
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 18 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 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
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 any term, clause, or provision of the main contract
and any term, clause, or provision of the attachments or exhibits thereto, the terms of the main contract
shall prevail and be controlling.
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.
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Recreation Services Agreement/ Rev. Sept. 2019
Page 6 of 7
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 (5th) 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:
Office of the City Manager
10300 Torre Ave., Cupertino, CA 95014
Cc: Representative/Coordinator:
Colleen Ferris
Email: colleenf@cupertino.org
To Contractor:
Cc: Representative/Coordinator:
JAHARA PAGADIPAALA
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.
SIGNATURES CONTINUE ON THE FOLLOWING PAGE
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Recreation Services Agreement/ Rev. Sept. 2019
Page 7 of 7
IN WITNESS WHEREOF, the parties have caused this contract to be executed.
CONTRACTOR
By ________________________
Name ______________________
Title ______________________
Date _______________________
Tax I.D. No.: Refer to W9
CITY OF CUPERTINO
A Municipal Corporation
By ________________________
Name ______________________
Title ______________________
Date _______________________
APPROVED AS TO FORM:
_____________________________
HEATHER M. MINNER
Cupertino City Attorney
ATTEST:
_____________________________
KIRSTEN SQUARCIA
City Clerk
Date _______________________
JAHARA PAGADIPAALA
JUNE 02, 2020
FITNESS INSTRUCTOR
Heather M. Minner
Jenny Koverman
Jenny Koverman
Jun 25, 2020
Recreation Supervisor
Jun 25, 2020
Updated 4/15/20
EXHIBIT A
SCOPE OF WORK, PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide FITNESS INSTRUCTOR in, but not limited to, the following:
YOGA
Location and Time of CONTRACTOR Services:
Refer to the Recreation Schedule dated MONTHLY FITNESS SCHEDULE 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, $40/class.
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 $3,000.00.
Eligible Participant Minimum and Maximums for CONTRACTOR Services:
Minimum: 15
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 Contractor 2 Contractor 3 Contractor 4
Contractor 5 Contractor 6 Contractor 7 Contractor 8
Contractor 9 Contractor 10 Contractor 11 Contractor 12
Contractor 13 Contractor 14 Contractor 15 Contractor 16
Contractor 17 Contractor 18 Contractor 19 Contractor 20
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):
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.)
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.)
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.
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.
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 mandatory 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
DATE (MM/00/ffiY)
01/07/2020
PRODUCER
Maguke Iniuiance Agency, Inc. FWI
I Bala Plz Ste 100
Bala Cynwyd, PA 19004-1401
610.617.7!100
THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMMEND, EXTEND OR
AITER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED
lahaia Pagadlpaala
INSURER A: Phlladelphla Indemnlty Insurance Company 18058
IN!alRER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHST ANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERIFICATION MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
Pal ICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEIEN REDUCED BY PAID CIAIMS.
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INSRD TfPE OF INSURANCE POLIC'f NUMBER
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DATE (MM/00/Yffll
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DATE (MM/DD/Y'ffl)LIMITS
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PERSONAL & ADV INILIRY e2,000,ODD
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PRODUCTS - COMP/OP AGG S4,000,000
AUTOMOBILE LIABILIT'f
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DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES / EXCLuSIONS ADD "D BY ENDORSEMENT / SPECIAL PROVISIONS
It Is understood and agreed that the following entlty is added as an additional insured but only with iespectls) to the opetatlons oT the named iiisuied except that liability resulting from the additlonal insuieds sole
negllgence.
CERTIFICATE HOLDER
Clty oT Cuperilno, 145 City counCll, BOaTdS and Commlislons, Officers, Officials, Employees,
Agents, Servants, VOlunteeTS and COnSultants
10300 Torie Ave
Cupertlno, CA 95014-
SHOLIID ANY OF THE ABOVE DESCR18ED POLICIES BE CANCELIED BEFORE THE EXPIRATION DATE
THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN NOTICE TO 'nlE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAIILIRE TO DO SO !iHALL IMPOSE NO OBLIGATION OR
LIABILffY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATiVES.
ALITHOR12ED REPRESENTATIVE
clC98
ACORD 25 (2009/01)
CANCELLATION
(c 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
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
10300TorreAve
Cupertino CA 95014-
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
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by your acts or
omissions or the acts or omissions of those acting
on your behalf:
1. In the performance of your ongoing operations;
or
2. In connection with your premises owned by or
rented to you.
However:
1. The insurance afforded to such additional
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.
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section Ill - Limits Of lnsurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1 , Required by the contract or agreement; or
2 . Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
CG 20 26 0413 @ Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY CHANGE DOCUMENT
POLICY NO:
CHANGE # 1 CHANGE EFFECTIVE: 01/03/2020
NAMED INSURED:Jahara Pagadipaala
MAILING ADDRESS
POLICY PERIOD:FROM 01/03/2020 TO 01/03/2021 at
12:01 A.M. Standard Time at your mailing address shown above.
DESCRIPTION:
In consideration of the premium reflected, the policy is amended as indicated below:
Insured Requested Addtional Insured & SAM Language City of Cupertino, its City Council, Boards
and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants
10300 Torre Ave. Cupertino CA 95014
Total Annual
Additional/Return Premium
Total Prorate
$0.00 Additional/Return Premium $0.00
Total Annual
Additional/Return
Tax/Surcharge/Fee $0.00
Total Prorate
Additional/Return
Tax/Surcharge/Fee $0.00
Page 1 of 1
Q uestions a bout y our Polic y?Report a Claim :Polic y Numb er :
1 -8 0 0 -2 C L A I M SCall 1 -8 0 0 -2 2 5 -7 0 1 4
A C TI O N RE Q UIRED :
PL E A S E R E V IE W A N D K E E P F O R Y O U R R E C O R D S .
T o t a l A n n u a l P r e m i u m : $2 ,9 8 3 .2 5
Polic y D e clara tio ns
Y o u r d i s c o u n t s a n d b e n e f i t s h a v e b e e n a p p l i e d . I n c l u d e s s t a t e s a l e s t a x a n d l o c a l s u r c h a r g e w h e r e a p p l i c a b l e .
Insuran c e In formatio n
N a m e d I n s ur e d :P o li c y N u m b e r :K a r i m u l l a R S h a i k h
J a h a r a B P a g a d i p a a l a
P o li c y P e ri o d :
D e c l a r a t i o n s E f f e c t i v e :
0 3 /3 1 /2 0 2 0 -0 3 /3 1 /2 0 2 1 1 2 :0 1 a .m .
s t a n d a rd t i m e a t t h e a d dr e s s o f t h e
N a m e d I n s ur e d
0 3 /3 1 /2 0 2 0
A f f i n i t y A f f i l i a t i o n :T e x a n s C r e d i t U n i o n
M a i l i n g A d dr e s s :
V ehicles C ov ered b y Y our A ut o Polic y
Y E A R M A K E M O D E L V E H I C L E I D N U M B E R
D riv er In f orm ation
N A M E S T A T E M A RI T A L S T A T U S
K a ri m u l l a R S h a i k h M1CA
J a h a r a B P a g a d i p a a l a M2CA
To ensure proper co v era g e , ple ase co n tact us if a n y inf ormatio n in y our polic y de claration is in accura te .
V I O L A T I O N P O I N T S A C C I D E N T P O I N T S
D RI V I N G R E C O R D P O I N T S :
V E H 1 : 00
V E H 2 : 00
V E H 3 : 00
P a g e o f THIS IS N O T Y O UR A U T O INSUR A N CE BILL. Y O U W ILL B E B IL L E D S EP A R A T E L Y . 1 4AUTO 3 0 7 9 1 0 1 9
Polic y Numb er :Report a Claim :W ant to A dd a C o v erage?
1 -8 0 0 -2 C L A I M SCall 1 -8 0 0 -2 2 5 -7 0 1 4 t o t a l k t o
y o u r a g e n t a b o u t t h e a v a il a b il i t y
o f t h i s c o v e r a g e a n d w h e t h e r i t
m e e t s y o ur n e e d s .
D IS C O U N T S A N D BE N EFIT S SE C TIO N
Y o u r d i s c o u n t s a n d b e n e f i t s h a v e b e e n a p p l i e d t o y o u r T o t a l A n n u a l Po li c y Pr e m i u m .
V ehicle Disc ounts
V EH 1 V EH 2 V EH 3
A n t i-L o c k B r a k i n g S y s t e m •••
P a s s i v e R e s t r a i n t - R e q u ir e s M e d P a y
(M o t o ri z e d S e a t B e l t s a n d /o r A ir B a g s)
•••
A n t i-T h e f t D e v i c e (s)••
Policy D isco unts
•••G o o d D ri v e r M u l t i-C a rAccount D i s c o u n t
•••E x c e p t i o n a l D ri v e r E l i t e D ri v e rPersistency D i s c o u n t
••A c c i d e n t F r e e D i s c o u n t M i n o r V i o l a t i o n F r e e D i s c o u n t
C o v era g e In f orm a tio n
Y o u r t o t a l a n n u a l p o l i c y pr e m i u m f o r a l l c o v e r e d v e h i c l e s i s s h o w n b e l o w . A p r e m i u m i s s h o w n f o r e a c h t y p e o f
c o v e r a g e y o u h a v e p ur c h a s e d f or e a c h v e h i c l e . W here no premium is sh o w n, you ha v e no t purc h ased the
indica t ed co v erage for th a t v ehicle .
C O V E R A G E LI M I T S PR E M I U M P E R V E H I C L E
V EH 1 V EH 2 V EH 3
A . Lia bilit y
B o d i l y I n j ur y E a c h P e r s o n
E a c h A c c i d e n t
$
$
2 5 0 ,0 0 0
5 0 0 ,0 0 0
Y e s Y e s Y e s
$4 3 7 $5 3 7$4 6 9
Pr o p e r t y D a m a g e E a c h A c c i d e n t$ 5 0 ,0 0 0
C . U ninsure d M ot orists
U n i n s u r e d M o t o ri s t s
B o d i l y I n j ur y E a c h A c c i d e n t
$
$
1 0 0 ,0 0 0
3 0 0 ,0 0 0
$5 4$4 8$5 0Each P e rs o n
Pr o p e r t y D a m a g e $E a c h A c c i d e n t 3 ,5 0 0 $1 3
P a g e o f THIS IS N O T Y O UR A U T O INSUR A N CE BILL. Y O U W ILL B E B IL L E D S EP A R A T E L Y . 2 4AUTO 3 0 7 9 1 0 1 9
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)
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 Jahara Pagadipaala.
I wish to enter into a services contract with the City of Cupertino. I am fully aware of the
provisions of section 3700 of the California Labor Code, which requires every employer to
provide Workers' Compensation coverage for employees in accordance with the provisions
of that Code. I am also aware that I must provide proof of workers’ compensation insurance
to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the
City of Cupertino’s contract.
I hereby certify that I do not have any employees nor will I have any employees working for
me or my business during the term of any service contract with the City of Cupertino. I am
not required to have Workers’ Compensation insurance.
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct.
Executed on this ____day of ____________, 2020, at , California.
______________________________
PRINT NAME
______________________________
SIGNATURE
02 JUNE CUPERTINO
JAHARA PAGADIPAALA
EXHIBIT D
Contractor’s Mandated Reporter Declaration
The undersigned does hereby certify that:
1. I am a representative of JAHARA PAGADIPAALA; that I am familiar with the facts
herein and am authorized and qualified to execute this declaration.
2. I declare that JAHARA PAGADIPAALA has complied with fingerprinting and criminal
background investigation requirements with respect to all Contractor’s employees who
may have contact with minors in the course of providing services pursuant to the
Agreement, and the California Department of Justice has determined that none of those
employees has been convicted of a felony, as that term is defined in California Penal Code
Section 11105.3.
3. I declare that each coach and administrator shall be required to successfully complete
concussion and head injury education at least once, either online or in person, before
supervising a participant, as required by California Health and Safety Code Section
124235, et seq.
4. On a yearly basis, all participants shall be required to sign and return a concussion and
head injury information sheet in compliance with California Health and Safety Code
Section 124235, which may be in the form attached as D-1.
5. That a complete and accurate list of Contractor’s employees, who may come in contact
with minors during the course and scope of the Agreement, are included below.
6. All of the below mentioned employees have tested negative for TB, or X-ray results for
TB, and have current documentation on file with Contractor.
7. All of the below mentioned employees have received training and understand their
responsibilities under the Mandated Reporter laws of this state and are willing and able to
comply.
List of all Contractor Employees working for the City (if no Employees, identify “self”):
self Contractor 2 Contractor 3 Contractor 4
Contractor 5 Contractor 6 Contractor 7 Contractor 8
Contractor 9 Contractor 10 Contractor 11 Contractor 12
Contractor 13 Contractor 14 Contractor 15 Contractor 16
Contractor 17 Contractor 18 Contractor 19 Contractor 20
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.
CONTRACTOR
By ________________________
Name ______________________
Title ______________________
Date _______________________
JAHARA PAGADIPAALA
FITNESS INSTRUCTOR
JUNE 02, 2020
Jahara Pagadipaala Contract
Final Audit Report 2020-06-25
Created:2020-06-09
By:Kevin Khuu (KevinK@cupertino.org)
Status:Signed
Transaction ID:CBJCHBCAABAA2CckM9fEZmNFeDPa2BVnp8oPBWs5N_55
"Jahara Pagadipaala Contract" History
Document created by Kevin Khuu (KevinK@cupertino.org)
2020-06-09 - 3:08:14 PM GMT- IP address: 73.158.53.147
Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval
2020-06-09 - 3:12:31 PM GMT
Document approved by Araceli Alejandre (aracelia@cupertino.org)
Approval Date: 2020-06-09 - 3:16:57 PM GMT - Time Source: server- IP address: 24.23.184.82
Document emailed to Heather M. Minner (minner@smwlaw.com) for signature
2020-06-09 - 3:16:59 PM GMT
Email viewed by Heather M. Minner (minner@smwlaw.com)
2020-06-09 - 8:24:59 PM GMT- IP address: 45.41.142.77
Document e-signed by Heather M. Minner (minner@smwlaw.com)
Signature Date: 2020-06-09 - 8:25:28 PM GMT - Time Source: server- IP address: 52.39.49.65
Document emailed to Jenny Koverman (jennyk@cupertino.org) for signature
2020-06-09 - 8:25:31 PM GMT
Email viewed by Jenny Koverman (jennyk@cupertino.org)
2020-06-25 - 2:59:51 PM GMT- IP address: 104.47.46.254
Document e-signed by Jenny Koverman (jennyk@cupertino.org)
Signature Date: 2020-06-25 - 3:00:14 PM GMT - Time Source: server- IP address: 73.70.28.255
Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature
2020-06-25 - 3:00:17 PM GMT
Email viewed by Kirsten Squarcia (kirstens@cupertino.org)
2020-06-25 - 7:46:42 PM GMT- IP address: 104.47.44.254
Document e-signed by Kirsten Squarcia (kirstens@cupertino.org)
Signature Date: 2020-06-25 - 7:46:52 PM GMT - Time Source: server- IP address: 148.64.105.190
Signed document emailed to Heather M. Minner (minner@smwlaw.com), cyrahc@cupertino.org, Jenny
Koverman (jennyk@cupertino.org), Kevin Khuu (KevinK@cupertino.org), and 2 more
2020-06-25 - 7:46:52 PM GMT