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18-001 Nancy McGinnis CITY OF No.1019 is FY2018-19 CUPERTINO RECREATION SERVICES AGREEMENT 1. Parties.This contract is made and entered into as of 7/1/2018 ("Effective Date'),by and between the City of Cupertino, a municipal corporation ("City"), and with NANCY MCGINNIS, ("Contractor"), a SOLE PROPRIETOR, for CURRENT EVENT AND COMPUTER INSTRUCTOR. 2. Services. Contractor agrees to provide the Services included in the Scope of Work and in accordance with the Schedule of Performance attached in Exhibit A. 3. Term. This contract begins on the Effective Date and ends on 6/30/2021 ("Contract Time"),unless extended or terminated as provided herein. Time is of the essence and Contractor must have sufficient time,resources, and qualified staff to deliver the Services as required. Contractor must promptly notify City of any actual or potential delays to afford the Parties adequate opportunity to address or mitigate such delays. 4. Compensation. City will pay Contractor for satisfactory performance of the Services an amount that will based upon actual costs but that will be capped so as not to exceed$6,400 BETWEEN 7/1/18 AND 6/30/19; $6,400 BETWEEN 7/1/19 AND 6/30/20; $6,400 BETWEEN 7/1/20 AND 6/30/21 ("Contract Price"),based upon the Scope of Services,budget,performance schedule,and rates included in Exhibit A. The maximum compensation includes all costs, expenses and reimbursements and will remain in place even if Contractor's actual costs exceed the capped amount. Contractor must submit invoices and the information required in Exhibit A in order to receive payment. City will compensate Contractor within 30 days after approval of written invoices. Invoices are subject to review and audit by City during regular business hours upon 24-hours' notice. Contractor must maintain complete and accurate records of payrolls, expenditures, disbursements and other cost items charged to City or establishing the basis for an invoice, for a minimum of four (4)years from the date of final payment. 5. Independent Contractor.Contractor is an independent Contractor and not an employee, partner, or joint venture of City. Contractor is solely responsible for the means and methods of performing the Services and for the persons hired to work under this Agreement.No civil service status or other right of employment will be acquired by virtue of Contractor's performance of the Services. Contractor is not entitled to City's health benefits, worker's compensation or any other benefit. Contractor must have the skills and qualifications to perform the Services in a competent and professional manner. Contractor will supply all tools, materials and equipment required to perform the Services under this Contract. Contractor is responsible for obtaining permits and licenses required by law and must obtain a City business license. 6. Proprietary/Confidential Information.To the extent Contractor may have access to i Recreation Services Agreement/Rev. 3-14-2018 Page 1 of 11 private or confidential information owned or controlled by the City, Contractor agrees to treat it confidential and use it solely to perform this Agreement. Contractor must exercise the same standard of care to protect City information as a reasonably prudent Contractor would use to protect its own proprietary data. 7. Ownership of Materials.To the extent Contractor prepares written material, drawings or data in connection with this contract, City will have the property rights to those materials and all copyrights,if any, to such work product will constitute City property. 8. Records.Contractor must maintain complete,accurate, and detailed accounting records relating to its performance in accordance with generally accepted accounting principles and procedures. The records must include detailed information about Contractor's services, benchmarks, deliverables and costs/fees,and must be made reasonably available to City.The records and supporting documents must be kept separate from other files and maintained for four years from the date of City's final payment. 9. Assignment. This Contract is not assignable. Contractor may not substitute another or transfer any rights or obligations under this Contract without prior written approval of City.Only those persons whose names are included in Exhibit A may perform the Services. 10. Publicity and Signs. Any publicity generated by Contractor related to this contract or the Services during the Contract Time and for one year thereafter must reference City contributions. The words "City of Cupertino" shall be displayed in all pieces of publicity, including flyers, press releases, posters, brochures, public service announcements, interviews and newspaper articles. No signs may be posted,exhibited or displayed on or about City property,except signage required by law or under this Agreement without prior written approval from City. 11. Indemnification. To the fullest extent allowed by law and except for losses caused by the sole negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend, and hold harmless the City, its City Council, boards and commissions, officers, officials, employees, agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal counsel acceptable to City, from and against any liability for damages, claims, actions, causes of action, demands,charges, losses, costs and expenses(including attorney fees, legal costs and expenses related to litigation,arbitrations,administrative and regulatory proceedings),of every nature,arising out of or in any way related to Contractor's or Contractor's agents performance of this contract or the Services. This includes but is not limited to Liability resulting in personal injury, death, property damage, or economic losses. Contractor must pay any costs City may incur in enforcing this provision and must accept a tender of defense upon receiving notice from City. Contractor's payments may be deducted or offset to cover any money the City lost due to a claim or counterclaim arising out of this Contract. 12. Insurance. Contractor shall comply with the insurance requirements in Exhibit B. City will not execute the Agreement until it has received and approved satisfactory certificates of insurance and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole discretion may purchase insurance and deduct the costs from payments to Contractor,or terminate the contract. Recreation Services Agreement/Rev. 3-14-2018 Page 2 of 11 13. Compliance with Laws and Other City Requirements. Requirements for all Contracts. This contract is subject to local, state and federal laws and regulations prohibiting discrimination,including Title VII of the Civil Rights Act of 1964,the California Fair Employment Practices Act,the Americans with Disabilities Act of 1990,and other laws that pertain to fair employment and anti-discrimination practices. Contractor must comply with labor laws pertaining to prevailing wages, working hours, overtime, payroll records, and other requirements imposed by the Department of Industrial Relations.If Contractor does not have employees,it must sign the Affidavit of No Employees, attached as Exhibit C. Consultant is responsible for verifying employment eligibility of employees pursuant to the Immigration Reform and Control Act of 1986. Contractor must comply with conflict of interest laws and regulations applicable to this Agreement and avoid conflicts of interest. Contractor may be required to file a conflict of interest form for engaging in governmental decisions or serving in a staff capacity,and is hereby advised to review the requirements of California Political Reform Act and the California Code of Regulations. Services may only be performed by persons who are not employed by City and who do not have a contractual relationship with City other than this contract. Contractor agrees to abide by City policies and administrative rules prohibiting gifts to City officials and employees. Additional Requirements for Services Provided to Minors: Contractor and its employees who provide services under this Agreement must comply with these additional requirements: A. Undergo fingerprinting and a criminal background check and verify all employees providing services under this contract have met this requirement. B. Complete a Tuberculosis screening test as required by law and as set forth in Exhibit D. C. Comply with the Mandatory Reporting under California Penal Code 11164-11174.3 and with the protocols, reporting, and training required under California Health and Safety Code Section 124235, AB2007, and other laws pertaining to concussion evaluation,removal from play, and return to play protocols. (Refer to Center for Disease Control & Prevention, https://www.cdc.gov/headsup/index.htm1j. D. Submit required forms and acknowledgments included in Exhibit D, and ensure its each participant is provided with a concussion information sheet, signs and returns the forms to the City as required by Health and Safety Code Section 124235. Require coaches and administrators to successfully complete the concussion and head injury education at least once either online or in person, before supervising a participant. Contractor shall offer training, educational materials, or both to each Contractor administrator on a yearly basis. (Training resources are available at the Center for Disease Control&Prevention(link cited above). E. If providing instruction, Contractor must acknowledge and comply with all requirements set forth in the Recreation&Community Services Instructor Manual. Recreation Services Agreement/Rev. 3-14-2018 Page 3 of 11 14. Coordination of Services. The Parties designate the following persons as Services Coordinators with the responsibility to oversee the delivery of Services in accordance with the terms of this Agreement. Contractor's designation and any substitution are subject to City approval. For City: For Contractor: Name:Justin Cecil Name: Nancy McGinnis Position:Recreation Coordinator Position: Instructor Contact:justinc@cupertino.org;408.777.3150 Contact: ( 15. Abandonment. City may abandon or postpone the Activity or Program and will notify Contractor as soon as possible. Contractor will be paid for satisfactory Services rendered through the date of abandonment upon submission of final invoices approved by City. 16. Termination. City may terminate this contract for cause or without cause at any time and will notify Contractor as soon as possible.Contractor will be paid for satisfactory services rendered through the date of termination upon submission of final invoices approved by City. 17. Governing Law,Venue and Dispute Resolution.This contract is governed by the laws of the State of California. Any legal actions or proceedings filed against_City in connection with this contract must comply with the government claims filing requirements and must be filed with the Superior Court for the County of Santa Clara, State of California. At City's request, Contractor is required to continue to provide Services pending resolution of any dispute. If the Parties elect arbitration, the arbitrator's award must be supported by law and substantial evidence and include detailed written findings of law and fact. 18. Attorney Fees. If City is required to pursue litigation,arbitration or other administrative or regulatory proceeding to enforce its rights or the terms of this Agreement, the prevailing party will be entitled to reasonable attorney fees and costs.This Section survives this Agreement. 19. Third Party Beneficiaries.There are no third party beneficiaries under this Contract. 20. Waiver.Neither acceptance of Services nor payment thereof constitutes a waiver of any contract provision. City waiver of a breach shall not constitute waiver of another term, provision, covenant or condition, or a subsequent breach,whether of the same or a different character. 21. Entire Agreement.This Agreement and all referenced Exhibits are hereby attached and incorporated into the Agreement by this reference and represent the full and complete understanding as to those matters contained herein, and supersede any other contract or understanding,either oral or written,between the Parties.This Agreement may not be modified or amended except in writing signed by both Parties.If there is any inconsistency between the main contract and any attachments or exhibits thereto, the main contract shall prevail. 22. Inserted Provisions.Each provision or clause required by law or this contract is deemed to be included and will be inferred herein. Either party may request an amendment to cure any mistaken insertion or omission of a required provision. Recreation Services Agreement/Rev. 3-14-2018 Page 4 of 11 23. Headings. The headings are for convenience only and are not a part of the contract or intended to affect, limit or amplify the terms or provisions of this Agreement. 24. Severability/Partial Invalidity.If any contract term or provision, or their application to a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or provision shall remain in force and effect to the extent allowed by such ruling.All other contract terms and provisions and their application to specific situations will remain in full force and effect. 25. Survival.All provisions which by their nature must continue after the Agreement ends, including without limitation Indemnification, Insurance, Ownership of Materials,Records, Governing Law and Attorney Fees, will survive the expiration or termination of this Agreement. 26. Notices.All notices and instruments pertaining to material provisions of this contract or significant disputes which are required by law or under this contract to be in writing must be sent to the persons listed below. The notices will be deemed effective on the date of personal delivery or the date confirmed by a reputable overnight delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid, registered or certified, or the next business day following electronic submission. To City of Cupertino: To Contractor: Office of the City Manager 38 Putnam Street, San Francisco, CA 94110 10300 Torre Ave., Cupertino CA 95014 cc:Representative/Coordinator: cc: Representative/Coordinator: Nancy McGinnis Justin Cecil Email:nancymcginnis@aol.com Email: justinc@Cupertino.org 27. Validity of Contract. This contract is valid and enforceable only if it complies with the provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or authorized designee, and is approved for form by the City Attorney's Office. 28. Execution. The person executing this contract on behalf of Contractor represents and warrants that Contractor has full right, power, and authority to execute this contract and to carry out all actions and services required. This contract constitutes a legally binding obligation of Contractor, and may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. Recreation Services Agreement/Rev. 3-14-2018 Page 5 of 11 IN WITNESS WHEREOF,the parties have caused this contract to be executed. CONTRACTOR CITY OF CUPERTINO Nancy McG' s A Municipal Corporation By Byd& Name Namee�f?4J'.ww Title %k Title S't ��/rc A✓ KCG i �e,�.,c�' Date -V t Tax I.D.No.: Refer to W9 APPROVED AS TO FORM: ATTEST: a RAN LPH STEVENSON HOM GRACE SCHMIDT Cupertino City Attorney City Clerk D Con tractlEncumbered Amount:$19,200 Account No.: 100-62-623 700-702 Recreation Services Agreement/Rev. 3-14-2018 Page 6 of 11 EXHIBIT A SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES The CONTRACTOR will provide CURRENT EVENTS FACILITATION AND COMPUTER INSTRUCTION in,but not Iimited to,the following: LET'S TALK CURRENT EVENTS FACEBOOK Location and Time of CONTRACTOR Services: Refer to the senior center newsletter dated JULY/AUGUST 2018,SEPTEMBER/OCTOBER 2018, NOVEMBER/DECEMBER 2018,JANUARY/FEBRUARY 2019,MARCH/APRIL 2019,MAY/JUNE 2019,JULY/AUGUST 2019, SEPTEMBER/OCTOBER 2019,NOVEMBER/DECEMBER 2019, JANUARY/FEBRUARY 2020,MARCH/APRIL 2020, MAY/JUNE 2020,JULY/AUGUST 2020, SEPTEMBER/OCTOBER 2020, NOVEMBER/DECEMBER 2020,JANUARY/FEBRUARY 2021, MARCH/APRIL 2021,MAY/JUNE 2021 for agreed upon dates,times,and class locations.The City,at its sole discretion,may change the agreed terms. Compensation for CONTRACTOR Services: Contractor shall be compensated for services performed pursuant to this Agreement.Compensation shall consist of the following:TWO HUNDRED TWENTY FIVE($225)PER CLASS MEETING OF CURRE�j FINAL Ro5?ERL EVENTS FACILITATION. EIGHTY PERCENT(80%)OF REVENUE GENERATED PER SESSION�F cDL4 N r COMPUTER INSTRUCTION.A TWENTY-FIVE($25)DOLLAR ADMINISTRATION FEE WILL BE DEDUCTED FROM THE FIRST PAYMENT.CONSULTANT SHALL PROVIDE ALL TEACHING SUPPLIES SUCH AS,BUT NOT LIMITED TO,DRY ERASE MARKERS,ERASERS,AND HANDOUTS.CONSULTANT PAYS FOR COPY SERVICE AT THE SENIOR CENTER AT$0.10 PER PAGE..The total compensation to the Contractor shall not exceed$19,200. Eligible Participant Minimum and Maximums for CONTRACTOR Services: CURRENT EVENTS FACILITATION Minimum: 1 Maximum: 100 COMPUTER INSTRUCTION Minimum: 3 Maximum: 15 If less than the required minimum number of participants enroll in and pay for a particular class as identified in the schedule before the class is scheduled to start,the City may cancel the particular class and/or terminate this Agreement without additional notice or payment to Contractor. Recreation Services Agreement/Rev. 3-14-2018 Page 7 of 11 List of all Contractor Employees working for the City of Cupertino (if no Employees,identify"self"): Performance of CONTRACTOR Services: In the case Contractor unilaterally cancels performance of a class,camp,activity or service without City approval,City reserves the right to immediately and without notice cancel the remainder of programs/services offered and or performed by Contractor. The Contractor shall follow all guidelines pertaining to registration procedures as listed in the quarterly recreation schedule.Participants may not take part in the program unless they are listed on the class roster or can show proof of enrollment.All participants and volunteers need to complete the City's Waiver of Liability form prior to taking part in the program.If applicable,contractors who are responsible for supervising minors must remain with the class until a parent of legal guardian has arrived and all minors are released to them. In the event of an injury occurring to a participant,the Contractor will notify the City within 1 hour and complete an Incident Report in the form approved by the City. The Incident Report must be submitted to the City within 24 hours of the injury occurring. Recreation Services Agreement/Rev. 3-14-2018 Page 8 of 11 EXHIBIT B INSURANCE REQUIREMENTS Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the Contractor,his agents,representatives,employees or subcontractors. MINIMUM SCOPE AND LIMIT OF INSURANCE Coverage shall be at least as broad as: 1. Commercial General Liability(CGL):Insurance Services Office Form CG 00 01 covering CGL on an "occurrence'basis,including property damage,bodily injury and personal&advertising injury with limits no less than$1,000,000 per occurrence.If a general aggregate limit applies,either the general aggregate limit shall apply separately to this project/location(ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Sexual Abuse/Molestation insurance or the equivalent are required for contracts involving children in after school activities,recreational programs,athletics, studies,transportation of students. Covers potential claims of abuse or child molestation. Sexual Abuse/Molestation coverage must be included under General Liability or obtained in separate policies in an amount of not less than$1,000,000 per occurrence ($2,000,000 aggregate) and$3,000,000 excess/umbrella coverage. 3.Automobile Liability:If applicable, a declaration page showing current proof of automobile insurance, displaying coverage amounts at or above the California statutory minimums,is required. 4. Workers'Compensation insurance as required by the State of California,with Statutory Limits, and Employer's Liability Insurance with limit of no less than$1,000,000 per accident for bodily injury or disease. (Note—required only if Contractor has employees). If the contractor maintains broader coverage and/or higher limits than the minimums shown above,the City requires and shall be entitled to the broader coverage and/or higher limits maintained by the contractor.Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. Self-Insured Retentions Self-insured retentions must be declared to and approved by the City.The City may require the Contractor to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall provide,or be endorsed to provide,that the self- insured retention may be satisfied by either the named insured or City. Other Insurance Provisions The general liability policy is to contain,or be endorsed to contain,the following provisions: 1.The City of Cupertino,its City Council,boards and commissions,officers,officials,employees, agents,servants,volunteers and contractors are to be covered as additional insureds with respect to Recreation Services Agreement/Rev. 3-14-2018 Page 9 of 11 liability arising out of work or operations performed by or on behalf of the Contractor including materials, parts or equipment furnished in connection with such work or operations. 2.For any claims related to this contract,the Contractor's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 20 010413 as respects the City,its City Council,boards and commissions, officers,officials,employees,agents, servants volunteers, and contractors. 3. The Insurance Company agrees to waive all rights of subrogation against the City,its elected or appointed officers,boards and commissions, officials,employees, agents, servants,volunteers and contractors for losses paid under the terms of any policy which arise from work performed by the Contractor for the City.This provision also applies to the Contractor's Workers'Compensation policy. 4. Each insurance policy required above shall provide that coverage shall not be canceled,except with notice to the City. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M.Best's rating of no less than A:VII,unless otherwise acceptable to the City. Verification of Coverage Contractor shall furnish the City with original certificates and amendatory endorsements effecting coverage required by this clause. All certificates and endorsements are to be received and approved by the City before work commences.The City reserves the right to require complete,certified copies of all required insurance policies,including endorsements affecting the coverage required by these specifications,at any time.We strongly recommend obtaining a copy of the policy declarations and endorsement page(make this a requirement in your Contract)to facilitate verification of coverages and spot any undesirable policy limitations or exclusions. Homeowner's Insurance In some cases the Contractor's homeowner's liability insurance may provide coverage sufficient to meet these requirements. Contractor should provide these requirements to his or her agent to confirm and provide verification to the City. Special Events Coverage for Contractors Special events coverage is available for an additional fee to provide the liability insurance required by this agreement. Contractor can obtain additional information and cost from the City. Special or Low Risk Activities City reserves the right to modify these requirements,including limits,based on the nature of the risk,prior experience,insurer,coverage,or other special circumstances.The City reserves the right to modify or waive insurance requirements for certain low risk recreational activities. EXHIBIT C AFFIDAVIT OF NO EMPLOYEES Recreation Services Agreement/Rev. 3-14-2018 Page 10 of 11 EXHIBIT C AFFIDAVIT OF NO EMPLOYEES State of California County of Santa Clara City of Cupertino I, the undersigned, declare as follows: I am an independent contractor and the owner of 41%N Al Z7 I wish to enter into a services contract with the City of Cupe tiro. 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 TZI day of C 2018, at ("Ttf California. Ai 7\—` `S PRINT NAU SI ATURE Recreation Services Agreement/Rev. 3-14-2018 Page 11 of 11 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 6365.12825080841231 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED) Alliant Insurance Services,Inc.in conjunction with City of Cupertino Apex Insurance Services P.O.Box 6450 Newport Beach,CA 92658 License No:OC 36861 NAMED INSURED(EVENT HOLDER): EVENT INFORMATION: Nancy McGinnis TYPE: Various Instructional Classes LOCATION: Cupertino Senior Center,21251 Stevens Creek Blvd,Cupertino,CA 95014 *Liquor Liability Yes No **Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless amended as described in Special Conditions. INSURANCE CARRIER:Evanston Insurance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES: EFFECTIVE: January01,2018 EXPIRATION: January 01, 2019 COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE Aggregate Limit $2,000,000 Products&Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal&Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance: Medical Payments(Any One Person) 5,000 MEGL1643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,00053,000,000 ❑ $2,000,000/$2,000,000 Property Damage(If purchased) No Property Damage Coverage The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: 01/11/2018 POLICY NUMBER: SEP41026 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 Person(s) Or Organization(s): City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees,Agents, Servants, Volunteers and Consultants For Certificate No.: 63651282508080841231 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 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 organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting on your behalf: amount of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by 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 Jan 121812:03p p.2 State Farm Mutual Automobile Insurance Cc npany900 Bakrs River Road w State Farm t aat &sk ersfiel�GA 93311 AT A-0177 A MCGINNIS,NANCY PREMIUM PAID:$784.92 DO NOT FAY. Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number:1053062902 Your State Farm Agent JOSHIN BRUGUERA INS AGCY INC Policy Number: Office:415-821.3600 Policy Period:November 29,2017 to May 29,2018 Address:399 CORTLAND AVE Vehicle: SAN FRANCISCO,CA 94114-x535 tf yx hate a new ordftMtca,have addedanydmVr,-orhm rmwd, Principal Driver: #9awcortad)vuragerd. NANCY MCGINNIS 'When you provide a deck as payment,you authorize us transfer,funds may be withdrawn from your account as soon either to use information from your check to make a as the same day we receive your payment,and you will not one-time electronic fund transfer from your account or to receive your check back from your financial institution. process the payment as a check transaction.When we use information from you,check to make an electronic fund Policy Number.240 8621-E29.05C Page number t of d Prepared October 24,2017 1004581 141582�? t r-12-2014 It's W- - hat You Know, Your auto insurance premium is$784.92. Did you know you may qualify fora discount? Call State Farm'Agent JOSHIN BRUGUERA INS AGCY fNC at '• „ 3" - -a 415-821-3600 r r a, tet.'. 'flat alr diseorrnis aro available in^airy stare,f nd discaunt anaotints m7y vary by Stare. l Jan 121812:03p p. , 0, SfateFarm VEHICLE INFORMATION Review your policy information carefully.If anything is incorrect,or if there are any changes,please let us know right away. Now is this vehicle normally used? Vehicle Idenflflcafion National average:12,006 rdEs driven Vehicle Description Number(VIN) Who principally drives this vehicle? annually per vehide With Drive Safe&Save'"",mileage information from your model.In addition.we review the comprehensive,collision, vehicle is used to determine your discount. Your calculated 'bodily injury and property damage claim experience annual mileage is 18,900. annually to determine which makes and models have Premium Adjustment earned decreases or increases from State Farm's standard rates.If any changes result from our reviews,adjustments Each year,we revievr our medial payments and personal injury protection coverages claim experience to determine are reflected in the rates shown on this renewal notice. the vehicle safety discount that is applied to each matte and DRIVER INFORMATION Assigned Driver(s) The following driver(s)are assigned to the vehicle(s)on this policy. Driver Driving Experience as of Marital Record Name Novembar2A 2017 Gender Status Level NANCY MCCiINNIS Principal Driver&Assigned Drivers Your premium may he influenced by the information shown For each automobile,the Principal Driver is the individual for these drivers. who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that he or she most frequently drives. C OVERAG E AND LIMITS see your policy for an explanation of these coverages. A Liability Bodily Injury 25OXY500,000 Property Damage 100.000 $$11 .44 C Medical Payments 5,000 a15.8.. D 100 Deductible Comprehensive $ 5 G 10,00 Deductible Colison $229r97.8.9 H Emergency Read Service R1 Car Rental 8 Travel Expense $25 Per Day, $600 Max ;16.60 U Uninsured MotorveNcie Bodily Injury 250,000!00,000 $6122 U1 Uninsured MotorVeNcle $4.49 Property Damara $784:92 Total Premium Page number 2 of 4 Po1iry Numoer,240 862'-E29-05C Prepared October 24,2017