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10-123 Agreement, Mahan and Sons, Inc., Tree Inspection Services CITY OF AGREEMENT V AAA / CITY OF CUPERTINO 10300 Torre Avenue CUPERTINO Cupertino, CA 95014 /� p 1/1 408- 777 -3200 NO. BY THIS AGREEMENT, made and entered into this 1 day of December, 2010, by and between the CITY OF CUPERTINO (Hereinafter referred to as CITY) and Mahan and Sons, Inc.; 5382 Alum Rock Avenue, San Jose, CA 95127, (408)761 -8480 (Hereinafter referred as CONTRACTOR), in consideration of their mutual covenants, the parties hereto agree as follows: CONTRACTOR shall provide or furnish the following specified services and /or materials: Provide tree inspection services for the purpose of characterizing tree attributes for City owned and maintained trees. Tree attribute data to be collected on a tree by tree basis, inputted into a City provided handheld device loaded with a tree inventory database. Required tree attribute data collected to include status, condition, species, location, location type, asset ID, grow space, diameter at breast height, height, and canopy. Supplemental comments are also to be provided as applicable. If significant deficiencies are noted, a work order request is to be submitted to the City. Completion of work to be coordinated with Jonathan Ferrante, Tree / ROW Supervisor. Transportation to be provided by contractor. EXHIBITS: The following attached exhibits hereby are made part of this Agreement: Mahan and Sons, Inc. estimate dated November 22, 2010. Article 1 — Insurance 1/413 Article 2 — Liability / Indemnification TERMS: The services and /or materials furnished under this Agreement shall commence on December 1, 2010 and shall be completed before May 31, 2011. COMPENSATION: For the full performance of this Agreement, CITY shall pay CONTRACTOR: $50 per hour for actual hours worked, not to exceed a total of $40,000. California Labor Code, Section 1771 requires the payment of prevailing wages to all workers employed on a Public Works contract in excess of $1,000.00. GENERAL TERMS AND CONDITIONS Hold Harmless. To the extent permitted by law CONTRACTOR agrees to indemnify, defend and hold harmless CITY, its officers, officials, employees, volunteers, agents and representatives, from and against any and all claims, demands, actions, causes of action, losses, damages, liabilities, or judgments known or unknown, and all costs and expenses, including reasonable attomeys' fees in connection with any injury or damage to persons or property to the extent arising directly or indirectly out of any negligence, error, omission, recklessness or willful misconduct of CONTRACTOR, or anyone for whom CONTRACTOR is legally liable in relation to the performance of services under this Agreement. Such defense and indemnification shall not apply in any instance of and to the extent caused by the sole negligence, recklessness or willful misconduct of CITY, its officers, officials, employees, volunteers, agents or representatives. Insurance. Should the City require evidence of insurability, Contractor shall file with City a Certificate of Insurance before commencing any services under this Agreement. Said Certificate shall be subject to the approval of City's Director of Administrative Services. Non - Discrimination. No discrimination shall be made in the employmert of persons under this Agreement because of the race, color, national origin, ancestry, religion or sex of such person. Interest of Contractor. It is understood and agreed that this Agreement is not a contract of employment in the sense that the relationship of master and servant exists between City and undersigned. At all times, Contractor shall be deemed to be an independent contractor and Contractor is not authorized to bind the City to any contracts or other obligations in executing this agreement. Contractor certifies that no one who has or will have any financial interest under this Agreement is an officer or employee of City. Changes. This Agreement shall not be assigned or transferred without the written consent of the City. No changes or variations of any kind are authorized without the written consent of the City. Page 1 CONTRACT CO- ORDINATOR and representative for CITY shall be: NAME: ic_ /lam oa � ;� � .K2 ' DEPARTMENT: �' e--, _ This Agreement shall become effective upon its execution by CITY, in witness thereof, the parties have executed this Agreement the day and year first written above. CONTRACTOR: CITY OF CUPE" IN•: By �� — � B Title PC - C S nl1cA )-So. r �, ,/ l / "1� L._ . Title: � . 7' r / z.� < Grd It../76e-s___ Soc. Sec. # or Tax I.D — APPROVALS EXPENDITURE DISTRIBUTION D • Nit_ �, ' ► AD ACCOUNT 1 �`O // 0 - 1 N R AMOUNT -- . � `7"" I dam, ∎,." . 1L`a�. / 1 1 ! ?' Wirlik7- 1 ,40- c,ey /// 0/ Page 2 Article 1: INSURANCE Contractor shall provide and maintain at all times during the performance of the Agreement the following insurances: 1.1 Workers' Compensation and Employer's Liability Insurance for protection of Contractor's employees as required by law and as will protect Contractor from loss or damage because of personal injuries, including death, to any of his employees. 1.2 Comprehensive Automobile Liability Insurance. Contractor agrees to carry a Comprehensive Automobile Liability Policy providing bodily injury liability. This policy shall protect Contractor against all liability arising out of the use of owned or leased automobiles both passenger and commercial. Automobiles, trucks, and other vehicles and equipment (owned, not owned, or hired, licensed or unlicensed for road use) shall be covered under this policy. Limits of liability for Comprehensive Automobile Liability Insurance shall not be less than $1,000,000 Combined Single Limit. 1.3 Comprehensive General Liability. Insurance as will protect Contractor and City from any and all claims for damages or personal injuries, including death, which may be suffered by persons, or for damages to or destruction to the property of others, which may arise from the Contractor's operations under this Agreement, which insurance shall name the City as additional insured. Said insurance shall provide a minimum of $1,000,000 Combined Single Limit coverage for personal injury, bodily injury, and property damage for each occurrence and aggregate. Such insurance will insure Contractor and City from any and all claims arising from the following: 1. Personal injury; 2. Bodily injury; 3. Property damage; 4. Broad form property damage; 5. Independent contractors; 6. Blanket contractual liability. 1.4 Contractor shall maintain a policy of professional liability insurance, protecting it against claims arising out of negligent acts, errors, or omissions of Contractor pursuant to this Agreement, in an amount of not less than $1,000,000. The said policy shall cover the indemnity provisions under this Agreement. 1.5 Contractor agrees to maintain such insurance at Contractor's expense in full force and effect in a company or companies satisfactory to the City. All coverage shall remain in effect until completion of the Project. 1.6 Contractor will furnish the City with certificates of insurance issued by Contractor's insurance carrier and countersigned by an authorized agent or representative of the insurance company. The certificates shall show that the insurance will not be cancelled, altered, or reduced without at least thirty (30) days' prior written notice to the Agreement between City of Cupertino and Mahan and Sons, Inc. — December 1, 2010 City. The certificates for liability insurance will show that liability assumed under this Agreement is included. Article 2: LIABILITY AND INDEMNIFICATION 2.1 Having considered the risks and potential liabilities that may exist during the performance of the Services; and in consideration of the promises included herein, City and Contractor agree to allocate such liabilities in accordance with this Article 2. Words and phrases used in this Article shall be interpreted in accordance with customary insurance industry usage and practice. 2.2 Contractor shall indemnify and save harmless and defend the City and all of their agents, officers, and employees from and against all claims, demand, or cause of action of every name and nature arising out of negligent error, omission, or act of Contractor, its agents, servants, or employees in the performance of its services under this Agreement. 2.3 In the event an action for damages is filed in which negligence is alleged on the part of City and Contractor, Contractor agrees to defend City. In the event City accepts Contractors's defense, City agrees to indemnify and reimburse Contractor on a pro rata basis for all expenses of defense and any judgment or amount paid by Contractor in resolution of such claim. Such pro rata share shall be based upon a final judicial determination of negligence or, in the absence of such determination, by mutual agreement. 2.4 Contractor shall indemnify City against legal liability for damages arising out of claims by Contractor's employees. City shall indemnify Contractor against legal liability for damages arising out of claims by City's employees. 2.5 Indemnity provisions will be incorporated into all Project contractual arrangements entered into by City and will protect City and Contractor to the same extent. 2.6 Upon completion of all services, obligations and duties provided for in the Agreement, or in the event of termination of this Agreement for any reason, the terms and conditions of this Article shall survive. 2.7 To the maximum extent permitted by law, Contractor's liability for City's damage will not exceed the aggregate compensation received by Contractor under this Agreement or the maximum amount of professional liability insurance required by this Agreement, whichever is greater. Agreement between City of Cupertino and Mahan and Sons, Inc. — December 1, 2010 Mahan and Sons Inc. Estimate 5382 Alum Rock Ave San Jose, CA 95127 Date Estimate # 11/22/2010 28 Name / Address City of Cupertino Jonathan Ferrante 10555 Mary Ave Cupertino, CA 95014 Project Description Qty Rate Total Input data for city street tree inventory. Approx. 6 trees per hr 1 50.00 50.00 depending on laptop functioning properly. Work time approx. 27 hrs per week,(weather permitting), if 2nd laptop provided approx 54 hrs per week. Rate $50/Hr. Thank you for your business. CA Lic # 932336 Total $50.00 f..,ii7 t , k California State Automobile Association Automobile Policy Declarations Inter - Insurance Bureau :1>' Please keep with your policy. PO Box 22221 See Important Notice on reverse. Oakland, CA 94623 - 2221 For questions or changes call: 1 -800- 922 -8228 DECLARATIONS TYPE PAGE o t. NAME AND ADDRESS OF INSURED Renewal Certificate 1 of 1 1111■1 Z 0 POLICY TYPE PROCESS DATE -..-- MNIIMMOM Member 07 -09 -2010 MAHAN DIANE X POLICY NUMBER INSURED SINCE 1267 7TH AVE o 6X 03 -88 -3 2003 �� SANTA CRUZ CA 95062 -2716 ?' FROM 12:01 A.M. Standard Time at the ---- address of the Named Insured, ---- � 08 -14 -2010 but not prior to the ti applied ��1�111�1�1��1111.. 1111.1.11.1. .111.111..1..111..11.111..1.11 u Your for or, i f this i a rep J Policy declarations, not prior to the time d Period coverage change was requested. _ TO 12:01 A.M. Standard Time at the �.......— 08 - 14 - 2011 address of the Named Insured. ° 4LTERNATE ADDRESS OCCUPATION ALTERNATE NUMBER TELEPHONE NUMBER 11111■ wwwww CITY OF CUPERTINO 464 -7687 761 - 8480 a ITEM I MAKE MODEL YR.! BODY TYPE VEHICLE IDENTIFICATION NU�ABER �■ Drivers I NAB �� w 02 i CHEV 1968 i 2D CP 124378L332427 .. do not DIANE °' v 03 FORD 2003 ` 4D WAG 1FMDU73K03ZA06369 �rnecssarily respond W to principally j operated ........... vehicles. .....■ COVERAGE LIABILITY LIMITS MN 02 ITEM 03 ITEM ___ ... _..._............ ..__I.T .4 . ........ _._...._.._...__.. -.. EACH PERSON EACH OCCURRENCE DEDUCT. i PREMIUM DEDUCT - -e I PREMIUM DEDUCT. PREMIUM DEDUCT PREMIUM Bodily 300,000 000 500,000 Injury - = $95 = $107 x Medical No Coverage 1 4 . . i _ ' Payments g No ICs 1<ve r a g�� ;Nei Cove r a ge _ __ Uninsured 300,000 500 000 $3 $45 to Motorists 2 —Damage party 100,000 $7 $114 i Lu i Comprehensive No Coiverage 500 n i . Actual Cash Value Less Deductible $68 { W Collision No Cover a 500 $15 € 3 Actual Cash Value Less Deductible , 9 • I • All Risks No Colve r a a No Cove r a n Actual Cash Value Less Deductible g 9e - j TOTAL PREMIUM PER VEHICLE ► $199 $492 - Automobile - EXPLANATION A- 515,000 first named insured. 8-515,000 each first named insured and spouse. LIMIT CODE PREMIUinsured. Death Benefits OF LMIT CODES C- $15,000 each editional named insured shown on endorsement F329. None Premium Summary CA Surcharge: $0.00 THIS IS NOT A BILL. Annual Premium: $691.00 • SCHEDULE OF CHANGES J e • t i f ITEM RATED DRIVER DSR YDE PRIOR ANN MILES FUTURE ANN MILES GARAGE ZIP VEHICLE USAGE GENDER MARITAL I 02 PT' 1,000 I 1,000 95062 Undesignated I i 03 DIANE 0 PT 38 5,000 I 5,000 I 95062 Principal F S FOR EXT 1 1 PT 1 € NATION OF P T CODES. Enhanced Transportation Expense Coverage: Item /s 03. DISCOUNTS: Mat Dry: None MultiPolicy H03 Homeowners: Item /s 02 03 Multi Car: Item /s 02 03 Good Driver: Item /s 02 03 ITEM nmi ISO - -- Ieaa' • ITEM Trot - ,_. ._._� �: < --- - - -... . :_„_"l ,_�_ aiiliggg cam= sr_ �_ _� = - _ _ ._'_"' �=�' __ - �... -::,_sue er* r I . -- -' -�.: ErMGE AUTOMATIC RENEWAL —This policy will be renewed automatically subject „` Personal n a I U m b re I I a to the premiums, rules and forms in effect for each succeeding policy �� , period. If our rules do not allow this policy to be renewed, we will give you vo written notice as required by law. Policy Declarations California State Automobile Association MEMBERSHIP NUMBER UMBRELLA POLICY NUMBER Inter- Insurance Bureau PO Box 22221, Oakland, CA 94623 -2221 168-26-26-5 PUP-06-87-14-5 NAMED INSURED(S) AND MAILING ADDRESS 04/08/2010 04 / 0 8/ 2 0 11 POLICY PERIOD —FROM TO MAHAN DIANE 12:01 A.M. STANDARD TIME AT the address of the named insured(s) as 1267 7TH AVE stated herein, or on the date and time shown in the application for this SANTA CRUZ CA 95062 policy, whichever is later, provided that all premiums required are paid when due and subject to all applicable provisions of this policy. POLICYHOLDER COPY RENEWAL MAIL DO REP DO REP NO PROCESS DATE ALT: (831) 464 -7687 HOME: (831) 464 -7687 16 16 361 02/10/2010 UNDERLYING INSURANCE This policy is issued in reliance on representation of the Named Insured(s) listed above that valid and collectible underlying insurance as shown in this section is now in force, and will at all times be in force, in at least the amounts shown, for each auto, watercraft, and recreational motor vehicle (including motorcycles) owned, leased by or furnished or available for regular use by you or any resident of your household, and for all residential premises owned, leased by or leased to any insured. An explanation of important terms appears on the reverse side of these Declarations. Defined words appear in the Definitions section of the policy. MINIMUM UNDERLYING LIMITS OF LIABILITY UNDERLYING BODILY INJURY COVERAGES PRCPERTY DAMAGE PERSONAL INJURY COMBINED SINGLE LIMIT per person/ a and or per occurrence per occurrence per offence per occurrence Residential Premises $500,000/ $500,000/ $500,000/ $500,000 $500,000 $500,000 $500,000 $500,000 Auto $500,000/ $100,000 $500,000 $500,000 Employer's Liability $100,000 5100,000 $100,000 $100,000 Recreational Motor Vehicle Liability $500,000/ (includes motorcycles, golf carts, $500,000 5100,000 $500,000 snowmobiles, trailers) Watercraft Liability $500,000/ 5500,000/ $500,000 $500,000 5500,000 $500,000 PERSONAL UMBRELLA COVERAGES AND LIMITS OF LIABILITY PREMIUMS NUMBER REVISION DATE POLICY AND ENDORSEMENTS ISSUED TO YOU BY US F1195C 09/2005 PERSONAL UMBRELLA POLICY LIMITS OF LIABILITY: $3,000,000 $353 F1188(07012009) 12/86/2818 10 :34 8314623984 MOORE AND MILLER PAGE 81/01 ACORN„ CERTIFICATE OF LIABILITY INSURANCE 1 DATE SINDOMY"") 12/00/2610 PRODUCER 831.462.6900 FAX 831.462.388 TaIS CERTIFICATE IS ISSUED AS A MATTER OF 84FORMATION INoare 3t Miller Insurance Agency ONLY AND COMERS NO RIGHTS UPON THE CERTF1CATE HOLDER. This CERT1FICATE DOES NOT MEND, EXTEND OR Li cen se No . 0A94420 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW P. D. Box 757 Cap i to1 a , CA 95010 INSURERS AFFORDING COVERAGE _ HAM 9 NSIRED a an and Sons, Inc. mS(A RA California Capital Ins. Co. _ -- 1267 7th Avenue INSURER& United Financial Casualty Co. 11770 Santa Cruz, CA 95062 INSURER c - INSURER 0; I INSURER E. �,r COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. MOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE PAY BE ISSUED OR MAX PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN} IS SUBJECT TO AU. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. AGGREGATE LOUTS SHOWN MAY HAVE BEEN REDUCED 6Y PAID CIAIN6. ^, TYPE OF INSURANCE POLICY RUYIER a > • a�f i iy �iiu WWI A,E LuTTY 3CMALO1.4R00 09 09 01/ 011 EACH OCCURRENCE s 1,000 000 X COMIERCIAL GENERAL UMUTY 0 ,,- _ a - _ s 100 000 ` CLAIMS MADE El OCCUR NOD EXP (Any ono pemorti s 5,000 A PERSONAL & AW INJURY S 1,000.000 111 � GENERAL AGGREGATE S 2,000,009 GEN1 AGGREGATE LIMIT APPLIES PER PRODUCTS • CONPfOP AGO s ,.._., 000, 000 X POLICY P im LOC ALITOINNIRX LIATITLITY 05490515-1 07/02/2010 1 07/02/2011 ammeommaxumff s ANY AUTO ma sowing 1, 000,000 AU.O'ASIED AUTOS BODILY INJURY S © SCHEOULEO ALTros (Per WW1) MIRED IUTOS LY I Y S I NON OWNED AUTOS PROPERTY GE $ GARAGE LAAELRT �_ . AUTO ONLY - ACCIDENT $ ANY AUTO UTICA THAN EA ACC $ AUTO ONLY' AGG >I owns t IRHS .LA LIABMY EACH OCCURRENCE ! 7 OCCUR CLANSMAN AGGREGATE $ s OEDUCTELE --, $ .. RETENTION S I $ WOROOtt OO.PENSATN}N TC o I is 1 !V- APID MUMMY UASIUTY .- Y 114 ANY PROPRIETORIPARTNBRIERECUTNE —1 I J_ EACH ACCIDENT $ DANwomloomm yy6666��Q� E MOM - EA EMPLOYEE t SPECIAL PRd4G IONS balmy E.L. MASS • POLICY LIMIT $ OTNBR E DESCRIPTION OP OPERATIONS i LOCAT14N5 VEHICLES t EXCLUSIONS Ammo ay EMOOnSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ASOVE 0€SCRBIEO POLICIES OR CAMGELLEO MOORE T E EXPINATV0 N DATE imam, THE IB!ma INSURER MU_ loamAvOR TO NIL 10 OATS WRITTEN NOTICE TO THE CERTIFICATE HOLDER RAYED TO THE LEFT, OUT FAAl1RE TO oo 50 SHALL The City of Cupertino NEE NO OSLIiAT Ot. Oft uARLN T OF ANT KIND uPON rot ITS .;, TS OR 10555 Mary Avenue arranammo J 1 Cupertino, CA 95014 _ea. RopRESENTATIVE T (A ' j � i` 1 Kristen Schnitt er / b i8 •. A4 I AcORD T 16 (2008101) FAX: 408.777.3399 0 1988 - 2009 ; - •• •717 - ' 77.r " - •,* - All -• 4 rved• The ACORD name and logo are registered marks of AGORD • CONTRACTORS STATE LICENSE BOARD 9821 Business Park Drive, Sacramento, CA 95827 800 32 STATE OF CALIFORNIA :` Meiling 1 Address: CSLB (275 P. O. Box 26000, Sacramento, CA 9582 Amold Schwarzenegger, Govemor www.cslb.ca.gov Exemption from Workers' Compensation Before the Contractors State License Board (CSLB) can issue a new license or reinstate, reactivate, or renew an existing license, the applicant or licensee must have on file a Certificate of Workers' Compensation Insurance or a Certificate of Self- Insurance issued by the Director of Industrial Relations, or must obtain an exemption by completing and submitting this form. To be exempt from workers' compensation, an applicant or licensee must submit this form to CSLB, certifying under penalty of perjury that he or she does not employ anyone in a manner that is subject to the workers' compensation laws of California. (See Business and Professions Code Section 7125.) DO NOT SUBMIT THIS FORM IF: • You have an inactive license. • The license qualifier is a Responsible Managing Employee (RME:). • You hold a C -39 Roofing classification — all contractors with a C -39 Roofing classification are required by Section 7125 to have a Certificate of Workers' Compensation Insurance or a Certificate of Self- Insurance on file with the Board. Contractors with a C-39 Roofing classification are not eligible for exemption from workers' compensation. • You have employees. For exemption from workers' compensation, complete the requested information, check only one of the boxes, and date and sign the form. Please type or print neatly and legibly in black or dark blue Ink. SECTION 1 - BUSINESS NAME AND ADDRESS FULL BUSINESS NAME (as it appears on the license) CSLB LICENSE OR APPLICATION FEE r' I �. r 0 Ck N- 01 5 7 N c / / Jt / C. NUMBER 9., 3 2 3 3 BUSINESS MAILING ADDRESS number /street or P.O. box city state ZIP code 5 8 IA L✓rl R tk../c -51,n 3' 3--( CA 7Sr BUSINESS STREET ADDRESS i2 number/street only — NO P.O. boxes city state ZIP code 53 3L T L ✓ r1 . , A-,. yt son St.2- ( C A I /L 7 BUSINESS PHONE NUMBER BUSINESS FAX NUMBER BUSINESS E -MAIL ADDRESS (903 ) j.51 - 0`f4'O (90e) Cziel-c 3 7 e l ScF/SI" e c.u ❑ CHECK THIS BOX IF THE ABOVE ADDRESS IS NEW. SECTION 2 - REQUIRED CHECK BOX YOU MUST CHECK ONLY ONE OF THE BOXES BELOW. Nir I do not employ anyone in the manner subject to the workers' compensation laws of California. OR ❑ lam an out -of -state contractor, and I do not hire employees who reside in California. (You must provide a certificate of insurance from your workers' compensation insurance carrier.) SECTION 3 — REQUIRED SIGNATURE FALSIFICATION OF ANY DOCUMENT IS GROUNDS FOR DISCIPLINARY ACTION. I certify under penalty of perjury under the laws of the State of Califomia that the information provided on this exemption statement is true and accurate. I understand that, upon employing anyone in a manner that is subject to the workers' compensation laws of the State of Califomia, the claim of exemption executed under this form will no longer be valid. I also understand that, as soon as I employ anyone subject to the California's workers' compensation laws, I must obtain a Certificate of Workers' Compensation Insurance, submit that certificate to CSLB within 90 days of its effective date, and continuously maintain the coverage provided by the certificate in accordance with the law. I further understand that failure to comply with this requirement is grounds for disciplinary action. (The definition of perjury" is telling a lie while under oath.) / Date Signature of Contractor (Owner, Partner, or Officer) Printed r , Name of Contractor (Owner, Partner, or Officer) to O -c c Zv 10 -� 0 A/ G c / a 11 n u h j p !Z s. NOTICE ON COLLECTION OF PERSONAL INFORMATION FOR CSLB USE ONLY CSLB collects the personal information requested on this form as authorized by Business and Professions Code Section 30 and Califomia Code of Regulations Section 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application for licensure or renewal unless you provide all of the requested information. You may review the records maintained by CSLB that contain your personal intimation, as permitted by the Information Practices Act. CSLB makes every effort to protect the personal information you provide us; however, it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law; or in response to a court or administrative order, a subpoena, or a search warrant For questions about the Department of Consumer Affairs' privacy policy o the Information Practices Act, contact the Office of Information Security and Privacy Protection at 1325 J Street, Suite 1650, Sacramento, CA 95814 or by e-mail to privacy©oispp.ca.gov. VIII 11III11 1111111111 III IIIIII HIl I II I I) 13L-50 (rev. 09/08) Exemption from Workers' Compensation - Page 1 of 1