17-001 Kim Marie SmithNO. )01'!I -O'/i
FY 17-18
AGREEMENT BETWEEN THE CITY OF CUPERTINO AND
KIM MARIE SMITH
FOR IPAD INSTRUCTION
THIS AGREEMENT, for reference dated TUESDAY, APRTL 25, 2017, is by and between CITY OF
CUPERTINO, a municipal corporation (hereinafter referred to as "City"), and KIM MARIE SMITH, an
Individual, whose address is (hereinafter referred to as
"Consultant"), and is made witli reference to the following:
RECIT ALS:
A. City is a municipal corporation duly organized and validly existing under the laws of the
State of California with the power to carry on its business as it is now being conducted under the
Constitution and the statutes of the State of California and tlie Cupertino Municipal Code.
B. Consultant is specially trained, experienced and competent to perform the special
services wliich will be required by tliis Agreement; and
C. Consultant possesses the skill, experience, ability, background, certification and
l<nowledge to provide the services described in this Agreement on the terms and conditions described
lierein.
D. City and Consultant desire to enter into an agreement for IPAD INSTRUCTION upon
the terms and conditions herein.
NOW, THEREFORE, it is mutually agreed by and between tlie undersigned parties as follows:
1. TERM:
The term of this Agreement shall commence on SATURDAY, J[JLY 1, 2017, and shall terminate
on SATURDAY, J[JNE 30, 2018, unless terminated earlier as set forth herein.
2.SERVICES TO BE PERFORMED:
Consultant shall perform each and every service set forth in Exhibit "A" which is attached liereto
and incorporated herein by tliis reference.
3.COMPENSATION TO CONSULT ANT:
Consultant shall be compensated for services performed pursuant to this Agreement in the
amount set forth below and as described in Exhibit "A" which is attached liereto and incorporated herein
by this reference. Compensation shall consist of the following: 80% of each student's registration. A $25
Annual Administration Fee will be deducted from the first payment. The contractor shall provide all
teaching supplies, such as, but not limited to, dry erase markers, erasers, and handouts. Copy service at
tlie senior center is 10 cents a page.
In the event that less than the required minimum number of participants shall request and pay
for services prior to tlie agreed upon time for the commencement of services to be performed by
Consultant, City may cancel and witlidraw from this Agreement. The total compensation to the
Consultant shall not exceed $7000.
4.ACKNOWLEDGEMENT OF MANDATED REPORTING RE0UIREMENTS AND
CONCUSSION PROTOCOL AND TRAINING:
A. Mandatory Reporting and Fingerprinting, and Consultant sliall comply with the
requirements of California Penal Code 11164-11174.3 and as set forth in Exhibit "B" which is
FY 2017/2018
Standard Consriltant Agreement I
attached l'iereto and incorporated herein by this reference.
B. Concussion Protocol: Consultant shall comply with all requirements of AB2007, including
those outlined in Health and Safety Code Section 124235, et seq. including concussion
evaluation, removal from play, and return to play protocols. (Resources are available at the
Center for Disease Control & Prevention. l'ittps://www.cdc.gov/lieadsup/index.litml)
1. Consultant shall provide each participant witli a concussion information slieet, wl'iich
may be in the form as attached as Exhibit C-I. Consultant shall ensure eacl'i
participant signs and returns the form as required by Health and Safety Code Section
124235; and
2. Consultant shall require all coaches ai'id administrators to successfully complete the
concussion and head injury education at least once either online or in person, before
supervising a participant. Consultant sliall offer training, educational materials, or
both to each consultant administrator on a yearly basis. (Training resources are
available at the Center for Disease Control & Prevention.
littps://www.cdc.gov/headsup/index.litn'il)
5. FINGERPRINT & TUBERCULOSIS (TB) CONSULT ANT DECLARATION:
Consultant agrees that all individuals covered under this Agreement sliall provide fingerprints for
criminal background test purposes and results of TB screening, pursuant to the reqriirements as set forth
in Exhibit "C" which is attached hereto and incorporated lierein by this reference.
6.TIME IS OF THE ESSENCE:
Consultant and City agree that time is of tlie essence regarding tlie performance of this
Agreement.
7. STANDARD OF CARE:
Consultant agrees to perform all services hereunder in a manner commensurate with the
prevailing standards of specially trained professionals in the San Francisco Bay Area and agrees tl'iat all
services shall be performed by qualified and experienced personnel who are not employed by the City
nor have any contractual relationship with City.
8.INDEPENDENT PARTIES:
City and Consultant intend tl'iat the relationship between them created by this Agreement is tl'iat
of an independent Consultant. The manner and means of conducting the work are under the control of
Consultant, except to the extent they are limited by statute, rule or regulation and the express terms of
this Agreement. No civil service status or other right of employment will be acquired by virtue of
Consultant's services. None of the benefits provided by City to its employees, including but not limited
to, unemployment insurance, workers' compensation plans, vacation and sick leave are available from
City to Consultant, its employees or agents. Deductions sliall not be made for any state or federal taxes,
FICA payments, PERS payments, or other purposes normally associated with an employer-employee
relationship from any fees due Consultant. Payments of the above items, if required, are the
responsibility of Consultant.
9. IMMIGRATION REFORM AND CONTROL ACT (IRCA):
Consultant assumes any and all responsibility for verifying the identity and employment
authorization of all of his/her employees performing work hereunder, pursuant to all applicable IRCA or
other federal, or state rules and regulations. Consultant shall indemnify and liold City liarmless from
FY 2017/2018
Standard Consultant Agreement 2
and against any loss, damage, liability, costs or expenses arising from any noncompliance of this
provision by Consultant.
10. NON-DISCRIMINATION:
Consistent with City's policy that liarassment and discrimination are unacceptable
employer/employee conduct, Consultant agrees tl'iat harassment or discrimination directed toward a job
applicant, a City employee, or a citizen by Consultant or Consultant's employee or subcontractor on the
basis of race, religious creed, color, national origin, ancestry, liandicap, disability, marital status,
pregnancy, sex, age, or sexual orientation will not be tolerated. Consultant agrees that any and all
violations of this provision shall constihite a material breach of this Agreement.
11.HOLD HARMLESS:
Consultant shall, to the fullest extent allowed by law, with respect to all services performed in
connection with the Agreement, indemnify, defend, and hold harmless the City and its officers, officials,
agents, employees and volunteers from and against any and all liability, claims, actions, causes of action or
demands whatsoever against any of them, including any injury to or death of any person or damage to
property or other liability of any nature, whether physical, emotional, consequential or otherwise, arising
ortt, pertaining to, or related to tlie performance of this Agreement by Consultant or Consultant's
employees, officers, officials, agents or independent contractors. Such costs and expenses shall include
reasonable attorneys" fees of counsel of City's choice, expert fees and all other costs and fees of litigation.
In addition to the obligations set forth above, Consultant shall indemnify, defend, and hold the
City, its elected and appointed officers, employees, and volunteers, harmless from and against any Claim
in which a violation of intellectual property rights, including but not limited to copyright or patent rights,
is alleged that arises out of, pertains to, or relates to Consultant's negligence, recklessness or willful
misconduct under tl'iis Agreement. Such costs and expenses shall include reasonable attorneys' fees of
counsel of City's choice, expert fees and all otlier costs and fees of litigation.
12.INSURANCE:
On or before the commencement of the term of this Agreement, Consultant shall fumish City
with certificates showing the type, amount, class of operations covered, effective dates and dates of
expiration of insurance coverage in compliaiice with the paragraphs below. Such certificates, which do
not limit Consultant's indemnification, sliall also contain substantially the following statement: "Should
any of tlie above insurance covered by this certificate be canceled or coverage reduced before the
expiration date thereof, the insurer affording coverage shall provide tliirty (30) days' advance written
notice to the City of Cupertino by certified mail, Attention: City Manager." It is agreed that Consultant
sl'iall maintain in force at all times during the performance of this Agreement all appropriate coverage of
insurance required by this Agreement with an insurance company that is acceptable to City and licensed
to do insurance business in tlie State of California. Endorsements naming the City as additional insured
shall be submitted with the insurance certificates.
A.COVERAGE:
Consultant shall maintain the following insurance coverage:
1. Workers' Compensation: Statutory coverage as required by the State of
California.
2. §: Commercial general liability coverage, including sexual abuse
and molestation coverage, in tlie following minimum limits:
1. Bodily Injury:$500,000 each occurrence
FY 2017/2018
Standard Consultant Agreement 3
$1,000,000 aggregate - all otlier
2. Property Damage: $100,000 each occurrence
$250,000 aggregate
If submitted, combined single limit policy witli aggregate limits
in the amounts of $1,000,000 will be considered equivalent to the
required minimum limits shown above.
3. Automotive: Proof of automobile insurance required at tlie California
statutory minimums.
B. SUBROGATION WAIVER:
Consultant agrees that in the event of loss due to any of the perils for which lie/she has agreed to
provide comprehensive general and automotive liability insurance, Consultant shall look solely to his/her
insurance for recovery. Consultant hereby grants to City, on bel'ialf of any insurer providing
comprehensive general and automotive liability insurance to either Consultant or City with respect to the
services of Consultant herein, a waiver of any right to subrogation wl'iicl'i any such insurer of said
Consultant may acquire against City by virtue of the payment of any loss under such insurance.
C.FAILURE TO SECURE:
If Consultant at any time during the term hereof sliould fail to secure or maintain tl'ie foregoing
insuraxtce, City shall be permitted to obtain sucli insurance in tlie Consultant's name or as an agent of the
Consultant and shall be compensated by the Consultant for the costs of the insurance premiums at the
maximum rate permitted by law and computed from the date written notice is received tliat the
premiums liave not been paid.
D.ADDITIONAL INSURED:
City, its City Council, boards and commissions, officers, employees and volunteers sliall be
named as an additional insured under all insurance coverages, except any professional liability insurance,
required by this Agreement. The naming of an additional insured sl"iall not affect any recovery to which
sucl'i additional insured would be entitled under tliis policy if not named as such additional insured. An
additional insured named l'ierein shall not be held liable for any premium, deductible portion of any loss,
or expense of any nature on this policy or any extension thereof. Any other insurance held by an
additional insured shall not be required to contribute anything toward any loss or expense covered by the
insurance provided by this policy.
E. SUFFICIENCY OF INSURANCE:
Tl'ie insurance limits required by City are not represented as being sufficient to protect
Consultant. Consultant is advised to confer with Consultant's insurance broker to determine adequate
coverage for Consultant.
13. CONFLICT OF INTEREST:
Consultant warrants tliat it is not a conflict of interest for Consultant to perform the services
required by this Agreement. Consultant may be required to fill out a conflict of interest form if the
services provided under this Agreement require Consultant to make certain governmental decisions or
serve in a staff capacity as defined in Title 2, Division 6, Section 18700 of the California Code of
Regulations.
14.PROHIBITION AGAINST TRANSFERS:
FY 2017/2018
Standard Consultant Agreement 4
Consultant shall not assign, sublease, liypotl'iecate, or transfer this Agreement, or any interest
therein, directly or indirectly, by operation of law or otlierwise, without prior written consent of City.
Any attempt to do so without said consent shall be null and void, and any assignee, sublessee,
hypothecate or transferee sliall acquire no rigl'it or interest by reason of such attempted assignment,
hypothecation or transfer. However, claims for money by Consultant from City under this Agreement
may be assigned to a bank, trust company or other financial institution witliorit prior written consent.
Written notice of sucli assignment sliall be promptly furnished to City by Consultant.
The sale, assignment, transfer or other dispositioi'i of any of the issued and outstanding capital
stock of Consultant, or of tlie interest of aiiy general partner or joint venturer or syndicate member or
cotenant, if Consultant is a partnership or joint venture or syndicate or cotenancy, which shall result in
changing the control of Consultant, shall be construed as an assignment of this Agreement. Control
means fifty percent (50%) or more of tlie voting power of tlie corporation.
15.SUBCONTRACTOR APPROVAL:
Unless prior written consent from City is obtained, only those people and subcontractors whose
names and resumes are attaclied to this Agreement shall be used in the performance of this Agreement.
In the event that Consultant employs subcontractors, sucli subcontractors shall be required to furnish
proof of workers' compensation insurance and sliall also be required to carry general, and professional
liability insurance in reasonable conformity to the insurance carried by Consultant. hi addition, any work
or services subcontracted hereunder sliall be subject to each provision of this Agreement.
16.PERMITS AND LICENSES:
Consultant, at his/her sole expense, shall obtain and maintain during the term of this Agreement,
all appropriate permits, certificates and licenses including, but not limited to, a City Business License, that
may be required in connection witli the performance of services hereunder.
17.REPORTS:
A. Each and every report, draft, work product, map, record and other document, l'iereinafter
collectively referred to as "Report", reproduced, prepared or caused to be prepared by Consultant
pursuant to or in connection witl'i this Agreement, shall be the exdusive property of City. Consultant
shall not copyrigl'it any Report required by this Agreement aiid sliall execute appropriate documents to
assign to City tl'ie copyright to Reports created pursuant to tliis Agreement. Any Report, information and
data acquired or reqriired by this Agreement shall become the property of City, and all publication rights
are reserved to City. Consultant may retain a copy of any report furnished to the City pursuant to this
Agreement.
B.All Reports prepared by Consultant may be used by City in execution or implementation
of:
1. Tl'ie original Project for wliicli Consultant was hired;
2. Completion of tlie original Project by otliers;
3. Subsequent additions to tlie original project; and/or
4. Other City projects as appropriate.
C. Consultant sliall, at such time and in such form as City may require, furnish reports
concerning the stahis of services required under tliis Agreement.
D. All Reports required to be provided by this Agreement shall be printed on recycled
paper. All Reports sliall be copied on both sides of the paper except for one original, whicli shall be
single sided.
FY 2017/2018
Standard Consultant Agreement 5
E. No Report, information or other data given to or prepared or assembled by Consultant
pursuant to this Agreement shall be made available to any individual or organization by Consultant
without prior approval by City.
18. RECORDS:
Consultant sl'iall maintain complete and accurate records with respect to sales, costs, expenses,
receipts and otl'ier such information required by City that relate to tlie performance of services under this
Agreement.
Consultant sliall maintain adequate records of services provided in sufficient detail to permit an
evaluation of services. All such records sliall be maintained in accordance witli generally accepted
accounting principles and sliall be clearly identified and readily accessible. Consultant shall provide free
access to such books and records to the representatives of City or its designees at all proper times, and
gives City tlie right to examine and audit same, and to make transcripts therefrom as necessary, and to
allow inspection of all work, data, documents, proceedings and activities related to this Agreement. Such
records, togetlier with supporting documents, shall be kept separate from other documents and records
and sliall be maintained for a period of three (3) years after receipt of final payment.
If supplemental examination or audit of tlie records is necessary drie to concerns raised by City's
preliminary examination or audit of records, aitd tlie City's supplemental examination or audit of the
records discloses a failure to adhere to appropriate internal financial controls, or other breach of contract
or failure to act in good faitli, then Consultai'it sliall reimburse City for all reasonable costs and expenses
associated with the supplemental examination or audit.
19.NOTICES:
All notices, demands, requests or approvals to be given under this Agreement shall be given in
writing aitd conclusively shall be deemed served wlien delivered personally or on tlie second business
day after the deposit thereof in the United States Mail, postage prepaid, registered or certified, addressed
as liereinafter
provided.
All notices, demands, requests, or approvals from tlie Consultant to the City shall be addressed to
tlie City at: 10300 Torre Ave., Cupertino, CA, 95014, Attention: Director of Recreation and Community
Services.
All notices, demands, requests, or approvals from City to Consultant shall be addressed to
Consultant at: 1421 MILLICH COURT, SAN JOSE, CALIFORNIA, Attention: KIM SMITH.
20.TERMINATION:
In the event Consultant fails or refuses to perform any of the provisions hereof at tlie time and in
tlie manner required hereunder, Consultant shall be deemed in default in the performance of this
Agreement. If such default is not cured witliin tlie time specified after receipt by Consultant from City of
written notice of default, specifying tlie nature of sucb default and the steps necessary to cure such
default, City may terminate tlie Agreement forthwith by giving to the Consultant written notice thereof.
City shall liave the option, at its sole discretion and without cause, of terminating tliis Agreement
by giving thirty (30) days' prior written notice to Consultant as provided herein. Upon termination of
tliis Agreement, eacli party shall pay to the other party that portion of compensation specified in tliis
Agreement that is earned and unpaid prior to tlie effective date of termination.
City lias no obligation to offer any of Consultant's services to participants, and, unless minimum
enrollment for a particular class identified in the Scope of Services is met, City may cancel tliat class
without further notice to Consultant or payment under this Agreement. The City in its sole discretion
may determine tlie type of classes, tlie number of classes and the assigned instructor.
FY 2017/2018
Standard Consultant Agreement 6
21.COMPLIANCES:
Consultant shall comply witl"i all state or federal laws and all ordinances, rules and regulations
enacted or issued by City. Consultant sliall obtain a Cupertino Business License and further comply with
the City"s Minimum Wage Ordinance as set forth in Cupertino Municipal Code Cl'iapter 3.37.
22. CONFLICT OF LAW:
This Agreement shall be interpreted rinder, and enforced by the laws of the State of California
excepting any clioice of law rules which may direct the application of laws of anotl'ier jurisdiction. The
Agreement and obligations of tlie parties are subject to all valid laws, orders, rules, and regulations of the
authorities liaving jurisdiction over this Agreement (or tlie successors of those authorities.)
Any suits brought pursuant to this Agreement sliall be filed witl'i the courts of the County of
Santa Clara, State of California.
23.ADVERTISEMENT:
Consultant shall not post, exl'iibit, display or allow to be posted, exhibited, displayed any signs,
advertising, show bills, lithograplis, posters or cards of any kind pertaining to tlie services performed
under this Agreement unless prior written approval lias been secured from City to do otherwise.
24.WAIVER:
A waiver by City of any breach of any term, covenant, or condition contained lierein sl'iall not be
deemed to be a waiver of any subsequent breach of the same or any otlier term, covenant, or condition
contained herein, wliether of the same or a different cliaracter.
25.INTEGRATED CONTRACT:
This Agreement represents the full and complete understanding of every kind or nature
whatsoever between the parties liereto, and all preliminary negotiations and agreements of whatsoever
kind or nature are merged herein. No verbal agreement or implied covenant shall be held to vary the
provisions hereof. Any modification of tliis Agreement will be effective only by written execution sigiied
by both City and Consultant.
26. INSERTED PROVISIONS:
Each provision and clause required by law to be inserted into the Agreement shall be deemed to
be enacted herein, and the Agreement sliall be read and enforced as thougli each were included herein. If
through mistake or otherwise, any such provision is not inserted or is not correctly inserted, the
Agreement shall be amended to make such insertion on application by eitlier party.
27.CAPTIONS:
The captions in this Agreement are for convenience only, are not a part of the Agreement and in
no way affect, limit or amplify tlte terms or provisions of this Agreement.
28. AGREEMENT COORDINATOR:
The Agreement Coordinator and representative for CITY sliall be, Jenny Koverman, Special
Programs Coordinator, Recreation & Community Service Department
FY 2017/2018
Standard Consultant Agreement 7
IN WITNESS, WHEREOF, tlie parties have caused the Agreement to be executed.
KIM MARIE SMITH
By:
Title:
Date:
KIM MARIE SMITH
INSTR'UCTOR
/,;ze>/iq
CITY OF CUPERTINO
A Municipal Corporation
Title: - SPECIAL P'ROGRAMS COORDINATOR
Date:5- 2S. l?-
RECOMMENDED FOR APPROV AL:
': KIM- FREY' - sUfflXVISORTitle: RECREATION
APPROVED AS TO FORM:
CITY ATTORNEY
GRACE SCHMIDT ,;, ,/ (,, ,(1
CITY CLERK
EXPENDI'IIJRE DISTRIBUTION:
Account No:
Amount:
100-64-24-600-639
$7000.00
FY 2017/2018
Standard Consultant Agreement
EXHIBIT A
CONSULT ANT SERVICES TO BE PERFORMED
The CONSULTANT will provide IPAD INSTRUCTION in, but not limited to, the following
programs:
IP AD PAINTING, IPAD A-Z
Location and Time of CONSULTANT Services:
Refer to the Recreation Schedule dated SENIOR CENTER NEWSLETTER 50+ SCENE for agreed upon
dates, times, and class locations. By the mutual agreement of both parties, class schedule may cliange.
Eligible Participant Minimum and Maximums for CONSULTANT Services:
Minimum: 3
Maximum: 10
If less tl'iai'i the required minimum number of participants enroll in and pay for a particular class as
identified in the scliedule before the class is scheduled to start, tlie City may cancel the particular class
and/or terminate this Agreement without additional notice or payment to Consultant.
Performance of CONSULTANT Services:
City shall liave no riglit of control as to tl'ie manner Consultant performs the services to be performed.
Nevertheless, City may, at any time, observe the maru'ier in which such services are being performed by
the consultant.
The Consultant shall follow all guidelines pertaining to registration procedures as listed in tlie quarterly
recreation schedule. Participaiits 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. Consultants are responsible for supervising
minors after class until a parent of legal guardian lias arrived.
In the event of an injury occurring to a participant, the Consultant will notify the City within I liour and
complete an htcident Report in the form approved by the City. The Incident Report must be submitted to
the City within 24 hours of the injury occurring.
FY 2017/2018
Standard Consultant Agreement 9
Named Insured
AT2 M-02-3738-FBOC F N
i 1. li l'li 1 i I ."
SMITH, KIM
1i1iillNlilll11il11l111liil1ili1illiliiilil1111iilll11i1iHlilil
A!DeDntsacn0dTMTailing Address
860 S WINCHESTER BLVD STE C
SAN JOSE GA 95128-2962
PHONE: (408) 248-9000
Businessowners Policy
Autoinatic Renewal - If tlie policy period is shown as 12 months, this policy will be renewed automatically sublectto the pretmums, rules an
fcii ms ni effect foi eac!i sticceeding policy period If ti'iis policy is termmated, we will give you and the Mortgagee/Lienholder written riouce If
compliance with tlie policy provisioris or as required by law
Entity: Individual
NOTICE. Infoi'mation coi'icerning changes in your policy language is included. Please call your agent
rf )iou l'iave any questions.
POLICY PREMIUM
Minimum Premium
Discounts Applied:
Renewal Year
Years in Business
Claim Record
$ 325.00
Prepared
APR 04 2017
CMP-4000
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SECTI(;)N I - PROPERTY SCHEDULE
Location
Number
Location of
Described
Premises
Limit of Insurance'
c'evuaai::ginegos -
Limit of Insurance"
Buscinoevsesr 7eerssonal
Property
Seasonal
Increase-
Business
Personal
Property
001
No Coverage $ 1,500 25%
' As of the effective date of ihis policy. the Liinit of Insurance as shown includes any increase in the limit due to Itiflation Coverage.
SECTION I - INFLATION (,OVEFIAGE INDEX(ES)
Cov A - In(lation Coverage Index:
Cov B - Consumer Price Index:
N/A
243.6
SECTION l- DEDUCTIBLES
Basic Deductible $1 ,000
Special Deductibles:
Money and Securities $250 Equipment Breakdown $1 ,000
Other deductibles may apply - reler Io policy.
Prepared
APR 04 2017
CMP-4000
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RENEWAL DECLARA'nONS (CONTINUED)
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SECTIONI. EXTENSIONe QF (,OVERAGE - LIMIT OF INSIJRANCE . EACH DES(;'RIBED PREMI§,E,,S
The coverages and corresponding limits shown below apply separately to each described premises shown in these
Declarations, unless indicated by "See Schedule." It a coverage dOeS net tiaVe a corresponding limit ShOWn belOW,
but has "Included" indicated, please refer to that policy provision for an explanation of that coverage.
COVERAGE
Accounts Receivable
On Premises
Off Premises
Arson Reward
Collapse
Damage To Non-Owned Buildings From Theft, Burglary Or Robbery
Debris Removal
Equipment Breakdown
Fire Department Service Charge
Fire Extinguisher Systems Recharge Expense
Forgery Or Alteration
Glass Expenses
Increased Cost Of Construction And Demolition Costs (applies only when buildings are
insured on a replacement cost basis)
Money And Securities (Off Premises)
Money And Securities (On Premises)
Money Orders And Counterfeit Money
Newly Acquired Business Personal Properfy (applies only if this policy provides
Coverage B - Business Personal Property)
Newly Acquired Or Constructed Buildings (applies only if this policy provides
Coverage A - Buildings)
LIMIT OF
1?43URANCE
$10,000
$5.000
$5,000
Included
Coverage B Limit
25o/o of covered loss
Included
$2,500
$5.000
$10.000
Included
10o/,
$2.000
$5,000
$1 ,000
$100,000
$250,000
Prepared
APFI 04 2017
CMP-4000
0n2040 9Qd
0 Copyright, State Farm Mutual Atitoinobile Insurance (,ompany, 2008
Includes copyrighted mateiial of Insurance Seivices Office,Inc, with ilS pelml €SIOll
Continued on Reverse Side of Page P' ckl(:! 3 c'lt '7
RENEWAL DECLARATIONS (CONTINUED)
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Ordinance Or Law - Equipment Coverage
Outdoor Property
Personal Effects (applies only (o those premises pnavided Coverage B - Business
Personal Property)
Personal Property Oll Premises
Pollutant Clean Up And Removal
Preseivation Of Property
Property Of Others (applies only to (hose premises provided Coverage B - Business
Personal Propeity)
Signs
Valuable Papers And Records
On Premises
Off Premises
Water Damage, Other Liquids, Powder Or Molten Material Damage
Included
$5,000
$2,500
$15,000
$10,000
30 Days
$2,500
$2,500
$10,000
$5,000
Included
SECT)ON I - EXTENSIONS OF COVERAGE - LIMIT OF INSUFIA,NCE - PER POLICY ,,,,
The coverages and corresponding limits shown below are the most we will pay regardless of the number of
described premises shown in these Declarations.
COVERAGE
Loss Of Income And Extra Expense
LIMIT OF
INSURANCE
Actual LOSS Sustained - 12 Man(hS
SECTION It - LIABILITY
COVEFIAGE
Coverage L - Business Liability
LIMIT OF
INSURANCE
$1 .OOO.OOO
Prepared
APFI 04 2017
CMP-4000
002040
0 Copyright, State Farm Mutual Automobile Insurance Ciompany, 2008
Includes copyriOhind material of Insurance Seivicgs Dffic3 Inc, with its permission
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RENEWAL DECLARATIONS (CONTINUED)
PeoulslcinyeNssuomwbnerrs Polic% MYllT2H6,OKIM
Coverage M - Medical Expenses (Any One Person)
Damage To Premises Flented To You
AGGREGATE LIMITS
Products/Completed Operations Aggregate
General Aggregate
$5,000
$300,000
LIMIT OF
INSURANCE
$2,000,000
$2,000,000
Eacti paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable
annual period. Please refer to Section II - Liability in the Coverage Form and any attached endorsements
Your policy consists of these Declarations, the BUSINESSOWNERS COVERAGE FORM shown below, and any o(her
forms and endorsements that apply, including those shown below as well as those issued subsequent to the
issuance of this policy.
FORMS AND ENDORSEMENTS
CMP-4101
FE-6999.2
CMP-4709
CMP-4705.1
CMP-4788.1
FD-6007
Businessowners Coverage Form
"Terrorism Insurance Cov Notice
Money and Securities
Loss of Income & Extra Expnse
Addl Insd Owners Lessee Sched
Inlgnd Marine Attach Dec
" New Form Attached
SCHEDULE OF ADDITIQNAL INTERESTS
Interest Type: Addl Insured-Section li
Endorsement #: CMP47861
Loan Number: N/A
CITY OF CUPERTINO
10300 TORRE AVE
CUPERTINO CA 950143255
Interest Type: Addl Insured-Sectiori II
Endorsement #: CMP47861
Loan Number: NiA
CENTRAL CONTRA COSTA SANIT AFIY
DISTRICT
50191MHOFF PL
MARTINEZCA 945534316
Prepared
APR 04 2017
CMP-4000
002041 294
@ Copyright, Siats Farm Mutual Automobile Insurance Company, 2008
Includes copyngh}ed matenel oflnsutsnce Servtces Otitc3 Inc, with its petinisiton
Continued on Reverse Side of Page )-!ltlc' 5 gi .'
RENEWAL DECLARATIONS (CONTINUED)
pBoulslcinyeNssuomwbnOerrs Poiic% MYlfT2H6,OKIM
This policy is issued by the State Farm General Irisurance Company.
Participating Policy
You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors
accordance with the Company's Articles of Incorporation. as amended.
In Wihiess Wliereof, the State Farm General Insurance Company has caused this policy to be signed by its President
Secretary at Bloomington, lllinois.
Secretary President
IMPORT AN"F" NOTICE:
Californla law requlres us to provlde you with informatlon for flllng complalnts wlth the
Insurance Department regardlng the coverage and senrlce provided under thls pollcy.
CreopmrepsleaninttasrlVsehhoauvldefbaellefdiletodreoanc!aaftseartlssyfoacu1oarnydagSrteaetmeeFnatromnaoprroyboleumr.agent or other con
Please forward such complaints to:California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
You also may call toll free at 1-800-927-HELP or vlsit www.lnsurance.ca.gov/01-consumers
Prepared
APFI 04 2017
CMP-4000
002041
@ Copyright, State Farm Mutual Automobile Insurance Company, 2008
Includes copytighmd material of Insurance Servicgti Office, Inc., with its permission
Continued on Next Page Page 6 of 'i
FIENEWAL DECLARATIONS (CONTINUED)
BPoulslcinyeNssuomw, MYllT2H6,KIM
NOTICE TO POLICYHOLDER:
For a coinprehensive description of coverages and forms, please reter to your policy.
Policy char>ges requested before the "Date Prepared", whicl'i appear on this notice, are effective on t)ie Renewal Date of l
policy ui'iless otherwise indicated by a separate ei"idorsemeiit, binder, or amended declaratioris. Any coverage forms attact
to this notice are also effective on the Renewal Date of this policy
Pclicy clianges requested after the "Date Prepared" will be sent to you as an amended declarations or as an endorsement
your policy Billing for any additiotaial premium for S(ICII changes will be mailed at a later date.
If, durit*g tlqe past year, you've acquired any valuable property items, made any improvements to insured property, or have at
questiot*s about your insurance coverage, contact your State Farm agent.
Please keep this with your policy
Your coverage amount...,
It iS up tO 90u tO ChOOSe the COVerage and LIMITS that meet }Our ileedS We recommend that 70u pllrChaSe a coverage fil
equal to the estimated replacement cost of your structure. Replacement cost estimates are available from building contractr
and replacement cost appraisers, or, your agent can provide an estimate from Xactware, Inc."using information you provi
about 80Ur structure. We can accept the type Of estimate }Ou Choose aS 10ng SS it provides a reasoriable leVel Of detail ab(
your structure. State Farm8does not guarantee that any estimate will be the actual future cost to rebuild your structure. Higi
limits are available at higher premiums. Lower limits are also available, as long as tt'ie amount of coverage rneets (
underwriting requirements. We encourage you to periodically review your coverages and limits with your agent and to notify
of any changes or additions to yocir structure.
Prepared
APR 04 2017
CMP-4000
@ Copyright, State Farm Mutual Automobile Insurance Company, 2008
Includes copyrighted material of Insurance Services Office, Inc., with its permission
P;inn = ill a
STATE FARM aENEFIAL IN3URANCE COMPANY
A STOCK covppyy WITH sove or:'rrces /N stoovimsroy, rwrqors INLAND MARINE ATTACHING DECLARATIONS
Policy Niiinber
Plo21Ry0nPtehrsiod 51UfeNctil7 Pills, EffNiralt7ionDla8ta
't!mlieepa\tiplye ppeierimodsbee!oincsaanond ends atl2 01 am standard
'R'icRg':d'mR,9%% 75085-3925
Named Insured
SMITH, KIM
M-02-3738-FBOC F N
ATT ACHING INLAND MARINE
Automatic Renewal - If the policy period is s)iown as 12 months, this policy will be renewed automatically subject to the premtums, rules and
forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in
compliance with the policy provisions or as required by law.
Annual Policy Premium Included
The above Premium Amountis included in the Policy Premium shown on the Declarations.
Your policy consists of these [)eclarations, the INLAND MARINE CONDITIONS shown below, and any other forms and endorsernents that
apply, including those shown below as well as those issued subsequent to the issuance of this policy.
Fomis, Options, and Endorsements
FE-6271
FE-8739
FE-8745
Amendatory Endorsement
Inland Marine Conditions
Inland Marine Computer Prop
See Reverse for Schedule Page with Limits
Prepared
APR 04 2017
FD-6007
002043
:t.: Co1iyn0m, Stalii Fai in Mimial Aulomoime InSlll ance Comliany, 20011
Incltides copynghied inmsrial of Instiriincii Siiivn.e+; Office,Inc, wllll 114) psninssion
b.lu blllt d i 11) .11 ."Ull 111il3).1 'l
ATTACHING INLAND MARINE SCHEDULE PAGE
ATTACHING INIJIND MARINE
END(IRSEMENT
NUMBER COVERAGE
FE-8745 Inland Marine Computer Prop
Loss of Income and Extra Expense
LIMIT OF
INSURANCE
25,000
25,000
DEDUCTIBLE
AMOUNT
500
ANNUAL
PREMIUM
Included
Included
OTIIER LIMITS AND EXCLUSIONS MAY APPLY-REFER TO YOUR POLICY
Prepared
APR 04 2017
FD-6007
(!D Copyrighl Staffi Farm Mutual Automobile Insurance Compaiiy. 2008
Includes ccipyngmed iiiaterial of liisuiance 5e+yt.iis 0itn;e,Inc, yv:tli llS.je+llTISSIOl1
OO2(1-1 'I
FEa 2
Page 4 of 4
In accordance with the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism
Risk Insurance Program Reauthorization Act of 2015, this disclosure is part of your policy.
FE-6999.2 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
Coverage for acts of terrorism is not excluded
from your currerit policy. However your policy
does contain other exclusions which may be ap-
plicable, such as an exclusion for nuclear hazard.
You are hereby notified that under the Terrorism
Risk Insurance Act, as amended in 2015, the def-
inition of act of terrorism has changed. As defined
in Section 1 02(1 ) of the Act: The term "act of ter-
rorism" means any act that is certified by the Sec-
retary of the Treasury-in consultation with the
Secretary of Homeland Security, and the Attorney
General of the United States-to be an act of ter-
rorism; to be a violent act or an act that is dan-
gerous to human life, property, or infrastructure;
to have resulted in damage within the United
States, or outside the United States in the case of
certain air carriers or vessels or the premises of a
United States mission; and to have been commit-
ted by an individual or individuals as part of an
effort to coerce the civilian population of the United
States or to influence the policy or affect the coo-
duct of the United States Government by coer-
cion. Under this policy, any covered losses
resulting from certified acts of terrorism may be
partially reimbursed by the United States Gov-
ernment under a formula established by the Ter-
rorism Risk Insurance Act, as amended. Under
the formula the United States Government
generally re:m5urses 85% tbrough 2015', 84%
beginning on January 1, 2016; 83o/o beginning on
FE-6999 2
January 1, 20)7; 82% beginning on January 'I,
2018; 8'lo/o beginning on January 4, 2019; and
80% beginning on January 1, 2020 of covered
terrorism losses exceeding the statutorily estab-
lished deductible paid by the insurance company
providing the coverage The Terrorism Risk Insur-
ance Act, as amended, contains a $100 billion
cap that limits u.s. Government reimbursement
as well as insurers' liability for losses resulting
from certified acts of terrorism when the amount
of such losses exceeds $100 billion in any one
calendar year If the aggregate insured losses for
all insurers exceed $100 billion, your coverage
may be reduced.
There is no separate premium charged to cover
insured losses caused by terrorism. Your insur-
ance policy establishes the coverage that exists
for insured losses. This notice does not expand
coverage beyond that described in your policy.
THIS IS YOUR NOTIFICATION THAT UNDER
THE TERRORISM RISK INSURANCE ACT, AS
AMENDED, ANY LOSSES RESULTING FROM
CERTIFIED ACTS OF TERRORISM UNDER
YOUR POLICY MAY BE PART(ALLY REIM-
BURSED BY THE UNITED STATES GOVERN-
MENT AND MAY BE SUBJECT TO A $100
BILLION CAP THAT MAY REDUCE YOUR COV-
ERAGE.
@, Copyright, State Farm Mutual Automobile Insurance Company, 2015