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17-001 Mona Ahuja I NO. a t7i e FY 17-18 AGREEMENT BETWEEN THE CITY OF CUPERTINO AND MONA AHUJA FOR YOUTH DANCE INSTRUCTION THIS AGREEMENT,is by and between CITY OF CUPERTINO,a municipal corporation (hereinafter referred to as"City"),and MONA AHUJA,a California SOLE PROPRIETORSHIP,whose address is (hereinafter referred to as"Consultant"),and is made with reference to the following: A. SCOPE OF SERVICES. Contractor shall provide or furnish the following specified services and/or materials:Youth Dance Instruction.Services are further described in Exhibit"A". B. TERM. The term of this Agreement shall commence on 9/25/2017,and shall terminate on 6/30/2018,unless terminated earlier as set forth herein. C. COMPENSATION. 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 hereto and incorporated herein by this reference. Compensation shall consist of the following:65%of resident fees.The total compensation to the Consultant shall not exceed$2,000.00. D. EXHIBITS. The following attached exhibits hereby are made part of this Agreement: N EXHIBIT A-Scope of Services N EXHIBIT B-Acknowledgement of Mandated Reporting Requirements, Receipt of Training,and Receipt of Penal Code Statutes.Required for any consultant working with minors. N EXHIBIT C-City of Cupertino,Consultant Declaration.Required for any consultant working with minors. GENERAL TERMS AND CONDITIONS 1. 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 out,pertaining to,or related to the 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 this Agreement. 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. 2. SUBCONTRACTING: Consultant has been retained due to their unique skills and Consultant may not substitute another,assign or transfer any rights or obligations under this Agreement. Unless prior written consent i FY 2017/2018 Short Form Agreement less than$5,000 1 from City is obtained,only those people whose names are listed this Agreement shall be used in the performance of this Agreement. 3. ASSIGNMENT: Consultant may not assign,transfer,or subcontract this Agreement or any portions thereof, without prior written consent of City. 4. ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS AND CONCUSSION PROTOCOLS AND TRAINING: A. Mandatory Reporting and Fingerprinting,and Consultant shall comply with the requirements of California Penal Code 11164-11174.3 and as set forth in Exhibit'B"which is attached hereto and incorporated herein by this reference. i 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.haps://w-Nvw.cdc.gov/headsup/index.html) 1. Consultant shall provide each participant with a concussion information sheet,which may be in the form as attached as Exhibit C-1. Consultant shall ensure each participant signs and returns the form as required by Health and Safety Code Section 'i 124235;and 2. Consultant shall require all coaches and administrators to successfully complete the concussion and head injury education at least once either online or in person,before supervising a participant. Consultant shall 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. https://www.cdc.gov/lieadsul2/­l*�ndex.htn-d) 5. FINGERPRINT&TUBERCULOSIS(TB)CONSULTANT DECLARATION: Consultant agrees that all individuals covered under this Agreement shall provide fingerprints for criminal background test purposes and results of TB screening,pursuant to the requirements as set forth in Exhibit"C"which is attached hereto and incorporated herein by this reference. 6. INSURANCE: On or before the commencement of the term of this Agreement,Consultant shall furnish City with certificates showing the type,amount,class of operations covered,effective dates and dates of expiration of insurance coverage in compliance with the paragraphs below. Such certificates,which do not limit Consultant's indemnification,shall also contain substantially the following statement: "Should any of the above insurance covered by this certificate be canceled or coverage reduced before the expiration date thereof,the insurer affording coverage shall provide thirty(30)days'advance written notice to the City of Cupertino by certified mail,Attention:City Manager." It is agreed that Consultant shall 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 the 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: L Workers'Compensation:Statutory coverage as required by the State of California. FY 2017/2018 Short Form Agreement less than$5,000 2 i ii. Liabili : Commercial general liability coverage,including sexual abuse and molestation coverage,in the following minimum limits: 1. Bodily Injury: $500,000 each occurrence $1,000,000 aggregate-all other 2. Property Damage: $100,000 each occurrence $250,000 aggregate If submitted,combined single limit policy with aggregate limits in the amounts of$1,000,000 will be considered equivalent to the required minimum limits shown above. iii. Automotive:Proof of automobile insurance required at the California statutory minimums. 7. SUBROGATION WAIVER: Consultant agrees that in the event of loss due to any of the perils for which he/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 behalf 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 which any such insurer of said Consultant may acquire against City by virtue of the payment of any loss under such insurance. 8. TERMINATION OF AGREEMENT: In the event Consultant fails or refuses to perform any of the provisions hereof at the time and in the manner required hereunder,Consultant shall be deemed in default in the performance of this Agreement. If Consultant fails to cure the default within the time specified and according to the requirements set forth in City's written notice of default,and in addition to any other remedy available to the City by law,the City Manager may terminate the Agreement by giving Consultant written notice thereof,which shall be effective immediately.The City Manager shall also have the option,at its sole discretion and without cause,of terminating this Agreement by giving seven(7)calendar days'prior written notice to Consultant as provided herein. Upon receipt of any notice of termination,Consultant shall immediately discontinue performance. 9. NON-DISCRIMINATION: Contractor shall not discriminate against a job applicant,employee,City employee,or a citizen on the basis of race,color,national origin,ancestry,religion,gender,sexual orientation or other protected class of such person. 10. INTEREST OF CONSULTANT: It is understood and agreed that this Agreement is not a contract of employment and,at all times, Consultant shall be deemed to be an independent Consultant and Consultant 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. City shall have no right of control as to the manner Consultant performs the services to be performed. Nevertheless,City may,at any time,observe the manner in which such services are being performed by the Consultant. Consultant shall comply with all applicable Federal,State,and local laws and ordinances including,but not limited to,unemployment insurance benefits,FICA laws,and the City business license ordinance. FY 2017/2018 Short Form Agreement less than$5,000 3 I 11. 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 with the performance of services hereunder. 12. REPORTS AND RECORDS: Each and every report,draft,work product,map,record and other document,hereinafter collectively referred to as'Report",reproduced,prepared or caused to be prepared by Contractor pursuant to or in connection with this Agreement,shall be the exclusive property of City. Contractor shall not copyright any Report required by this Agreement and shall execute appropriate documents to assign to City the copyright to Reports created pursuant to this Agreement. Any Report,information and data acquired or required by this Agreement shall become the property of City,and all publication rights are reserved to City. Contractor may retain a copy of any report furnished to the City pursuant to this Agreement. Contractor shall maintain complete and accurate records with respect to sales,costs,expenses, receipts and other such information required by City that relate to the performance of services under this Agreement,in sufficient detail to permit an evaluation of services. All such records shall be maintained in accordance with generally accepted accounting principles and shall be clearly identified and readily accessible. Contractor shall provide free access to such books and records to the representatives of City or its designees at all proper times,and gives City the 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,together with supporting documents,shall be kept separate from other documents and records and shall be maintained for a period of three(3)years after Contractor receives final payment from City for all services required under this agreement. 13. CHANGES: No changes or variations of any kind are authorized without the written consent of the City. 14. COMPLIANCES: Consultant shall comply with all state or federal laws and all ordinances,rules and regulations enacted or issued by City. Contractor shall obtain a Cupertino Business License and further comply with the City's Minimum Wage Ordinance as set forth in Cupertino Municipal Code Chapter 3.37. 15. AGREEMENT COORDINATOR: The Agreement Coordinator and representative for CITY shall be:Karen Levy,Recreation Coordinator,Recreation&Community Service Department. FY 2017/2018 Short Form Agreement less than$5,000 4 i IN WITNESS,WHEREOF,the parties have caused the Agreement to be executed. MON CITY OF CUPERTINO A ' al Corporation C MON AHUJA By: KAREN LEVY Title: DANCE NSTR CTOR Title: RECREATION COORDINATOR Date: 2Z f /� Date: � 22 RECOMMENDED FOR APPROVAL: JEFFREY S.MILKES Title: DIRECTOR,RECREATION&COMMUNITY SERVICES APPROVED AS TO FORM: /RANDOLPH STEVENSON HOM CITY ATTORNEY ATTEST: r GRACE SCHMIDT CITY CLERK EXPENDITURE DISTRIBUTION: Account No: 580-63-620-700-702 Amount: $2000.00 FY 2017/2018 Short Form Agreement less than$5,000 5 EXHIBIT A CONSULTANT SERVICES TO BE PERFORMED The CONSULTANT will provide YOUTH DANCE INSTRUCTION in,but not limited to,the following programs: BOLLY BABIES,PRINCESS TAP/BALLET Location and Time of CONSULTANT Services: Refer to the Recreation Schedule dated FALL17-SPRING 18 for agreed upon dates,times,and class locations. By the mutual agreement of both parties,class schedule may change. I Eligible Participant Minimum and Maximums for CONSULTANT Services: Minimum: 5 Maximum: 12 If less than the required minimum number of participants enroll in and pay for a particular class as identified in the schedule before the class is scheduled to start,the City may cancel the particular class and/or terminate this Agreement without additional notice or payment to Consultant. Performance of CONSULTANT Services: In the case Consultant unilaterally cancels performance of a class,camp or activity without City approval, City reserves the right to immediately and without notice cancel the remainder of programs offered by Consultant. The Consultant 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. Consultants are responsible for supervising minors after class until a parent of legal guardian has arrived. In the event of an injury occurring to a participant,the Consultant 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. FY 2017/2018 Short Form Agreement less than$5,000 6 i i EXHIBIT B ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS,RECEIPT OF TRAINING,AND RECEIPT OF PENAL CODES STATUTES A mandated reporter is an individual who is obligated by law to report suspected cases of child abuse and neglect. In general,any individual who,in the ordinary course of their employment,has contact with children is a mandated reporter. Mandated reporters include child care workers,teachers and coaches. (California Penal Code 11165.7). If your job duties as an employee or an independent contractor of MONA AHUJA include contact with children,you are a Mandated Reporter. Prior to commencing employment and as a prerequisite of that employment,California law requires that you sign a statement to the effect that you have knowledge of the provisions of the Mandated Reporter Law,and will comply with those provisions. (California Penal Code 11166.5). The following are the Mandated Reporter responsibilities under California law. You are also being provided with a separate informational document which includes the text of the California Mandated Reporter Law and contact information for Child Abuse and Neglect Reporting for the County of Santa Clara.Please review this information carefully and acknowledge your receipt and understanding where indicated. If you have questions or concerns about this form or your Mandated Reporter responsibilities, please contact the Recreation Supervisor at 408-777-3120. I understand that: • By virtue of my employment or independent contractor status with MONA AHUJA,and because my employment requires me to have contact with children,I am a Mandated Reporter as defined by California Penal Code 11165.7. • The following situations trigger mandatory reports: a)Physical Abuse(willful harming of a child);b)Sexual abuse including sexual assault,child exploitation,pornography,and trafficking;c)Severe or General Neglect;and d)Extreme Corporal Punishment(resulting in injury). (Cal.Pen. Code 11165 et.seq.) I further understand that I may,but am not required to,report suspected Emotional Abuse. • If I reasonably suspect that a child is being abused,I must immediately make a telephone report. I must follow up with a written report within 36 hours. This report may be made to local law enforcement,or County Sheriff's Department,Probation Department or Child Welfare Agency. (Cal Pen.Code 11166(a)). • 1 am not required to,but I may,share information about suspected abuse with my supervisor or management or the parents of the alleged victim. • When I make a mandated report,I will be required to give my name. However,my identity will be kept confidential unless I either consent to disclosure or if the disclosure is made pursuant to a court order.Further,agencies investigating the mandated report may disclose my identity to one another. (Cal Pen.Code 11167(d)). i i FY 2017/2018 Short Form Agreement less than$5,000 7 i • The following agencies and individuals receiving or investigating mandated reports may disclose my identity to one another: o Prosecutors in a criminal prosecuting or in an action initiated under section 602 of the Welfare and Institutions Code arising from alleged child abuse; o Counsel appointed pursuant to subdivision(c)of Section 317 of the Welfare and Institutions Code; o A licensing agency when abuse or neglect in out-of-home care is reasonably suspected. (Cal Pen.Code 11167.5) • I may not be disciplined,dismissed,retaliated against,discriminated against or harassed for making a mandated report of reasonably suspected child abuse. • As a Mandated Reporter,I have civil and criminal immunity when making a report(Cal Pen.Code 11172). • As a Mandated Reporter,it is a misdemeanor to fail to comply with Mandated Reporting laws and I can be held criminally liable for failing to report suspected abuse. The penalty for this is up to six months in County jail,a fine of not more than $1000,or both. I further understand I could be civilly liable for failure to report.(Cal. Pen.Code 11166(c)). I have been provided with a copy of California Penal Code sections 11164-11174.3(Mandated Reporter Law). I understand that I am a legally Mandated Reporter. I am aware of and understand my responsibilities under the Mandated Reporter laws of this state and am willing and able to comply. I understand that a copy of this Acknowledgement will be kept in my personnel file. MO f r By: MONA AHUJA Title: DANCE INSTRUCTOR Date: FY 2017/2018 Short Form Agreement less than$5,000 8 EXHIBIT C CITY OF CUPERTINO CONSULTANT DECLARATION The undersigned does hereby certify that: 1. 1 am a representative of MONA AHUJA;that 1 am familiar with the facts herein and am authorized and qualified to execute this declaration. 2. I declare that MONA AHUJA has complied with fingerprinting and criminal background investigation requirements with respect to all Consultant's employees who may have contact with minors in the course of providing services pursuant to the Agreement,and the California Department of Justice has determined that none of those employees has been convicted of a felony,as that term is defined in California Penal Code Section 11105.3. 3. 1 declare that each coach and administrator shall be required to successfully complete concussion and head injury education at least once,either online or in person,before supervising a participant,as required by California Health and Safety Code Section 124235,et seq. 4. On a yearly basis,all participants shall be required to sign and return a concussion and head injury information sheet in compliance with California Health and Safety Code Section 124235, which may be in the form attached as C-1. 5. That a complete and accurate list of Consultant'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 Consultant. 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 Consultant Employees working for the City of Cupertino(if no Employees,identify"self'): self 8. The Consultant 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. NA AHU By: MONA AHUJ Title: DANCE INSTRUCTOR Date: ! 2 FY 2017/2018 Short Form Agreement less than$5,000 9 Contractor/Consultant Affidavit of No Employees State of California County of Santa Clara City of Cupertino I, the undersigned, declare as follows: I am an independent dance instructor. 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 ;Zday of , 2017, atY�jo D , California. Monte AME IGNATU E POLICY NUMBER: 6BRPG0000006030600 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Persons Or Organization(s) City of Cupertino, its City Council, boards &commissions, officers, employees &volunteer 10300 Torre Avenue Cupertino, CA 95014 Re: Mona Ahuja Cp# 1330 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section If — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to Section organization(s) shown in the Schedule, but only with III— Limits Of Insurance: respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" caused, required by a contract or agreement, the most we will in whole or in part, by your acts or omissions or the pay on behalf of the additional insured is the amount acts or omissions of those acting on your behalf: of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or Available under the applicable Limits of 2. In connection with your premises owned by or 2. rented to you. Insurance shown in the Declarations; However: whichever is less. 1. The insurance afforded to such additional This endorsement shall not increase the applicable insured only applies to the extent permitted by Limits of Insurance shown in the Declarations, 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. CG 20 26 04 13 ©Insurance Services Office, Inc.,2012 Page 1 of 1 ACO` n® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group,Inc. ac,No Ext: 1-800-506-4856 FAX No: 1-260-459-5590 1712 Magnavox Way E-MAIL Fort Wayne IN 46804 ADDRESSinfo@fitnessinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Mona Ahuja INSURER B: A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01103209 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS: TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMUC MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006030600 09/15/2017 09/15/2018 EACH OCCURRENCE $1,000,000 CLAIMS OCCUR 2:26 PM EDT 12:01 AM DAMAGE T RENTED $300 1)00 MADE PREMISES(Ea Occurrence MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG $1,000,000 POLICY ❑PRO ❑LOC PROFESSIONAL LIABILITY $1,000,000 JECT OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 -76 MB-1—N—E DUS IN LE LIMIT AUTOMOBILE LIABILITY (Ea accident ANY AUTO BODILY INJURY(Per person) OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) ONLY AUTOS HIRED NON-OWNED PROPERTY DAMA E AUTOS ONLY AUTOS ONLY (Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ YIN E.L.EACH ACCIDENT F' EXECUTIVEOFFICER/MEMBER ❑ E.L DISEASE—EA EMPLOYEE EXCLUDED?(Mandatory in NH) LEi If yes,describe under DESCRIPTION E.L DISEASE—POLICY LIMIT OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL k EXCESS MEDICAL C DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Non-certified Instructor of:Ballet,Cultural/ethnic,Jazz,Tap The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION City of Cupertino,its City Council,boards&commissions,officers, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE employees&volunteer THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10300 Torre Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Cupertino,CA 95014 AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) Coverage is only extended to U.S.events and activities. **NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Customer Copy -AKHIL AF UJA Page 2 of 2 MSRP base: 0.00 MSRP additional equip: 0.00 Odometer Information Odometer reading: 38,895 Odometer date: 03-2014 Vehicle Usage Annual miles: 12,000 Use of vehicle: PLSR/WK/SCH Household Driver Details MONA AHUJA Birth date: AKHIL AHUJA Birth date: Additional Interests Lienholders NONE Additional Insured/Lessors NONE Insurance Certificates NONE Endorsements Number Eff Date End Date Description 0021A ORIGINAL COST OF CUSTOMIZATION 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING 6128AC 03-14-2016 AMENDATORY ENDORSEMENT The information on this document is presented for general informational purposes only and is not intended to serve as a declaration page or policy. State Farm Mutual Automobile Insurance Company, Bloomington,Illinois https://sfiiet.opr.statefann.org/sysapv/printOptionsAction.do 9/25/2017 Customer Copy-AKML AHUJA Page 1 of 2 Customer name:AKHIL AHUJA Company: SF Mutual Address:25500 CRESCENT LN Servicing Agent: NED GARDNER LOS ALTOS HLS, CA 94022- Eff date:09-14-2017 to 03-14-2018 4589 Description: Policy:464 9756-C14-75 VIN: Status: PAID IN FULL SFPP#: POLICY NOT ON SFPP Premium/Billing Information Amount Due: 0.00 Total premium: 548.41 Last amount paid: 548.41 Date paid: 08-23-2017 Previous premium: 528.32 Premium refund: 0.00 Additional Policy Details Policy form: 9805B Coverage Details The premium amounts shown reflect a six-month policy term. Code Description Amount Total: Vehicle Details Year: https://sfnet.opr.statefarm.org/sysapv/printOptionsAction.do 9/25/2017 'i ,IFICATION CARDS MUTL VOL ® , ' FOLD TOP AND BOTTOM OF CARD ON PERFORATION Statefarm CALIFORNIA INSURANCE CARD State Farm MutcMl Automobile Insurance Company gooold INSURED River RoaaAKHILsfield,CA 93311 NIUTL VOL \RD IN YOUR CAR. CARD,WITH YOUR VEHICLE REGISTRATION RENEWAL. IL THE EFFECTIVE DATE OF THIS CARD. SYS PENDS L I