18-001 Sa-Ad Kongboon CITY OF
No.
III FY2018-20
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 SA-AD KONGBOON,
("Contractor"), a FITNESS INSTRUCTOR for YOGA.
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 6/30/2020 ("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$5,000.00("Contract
Price"),based upon the Scope of Services,budget,performance schedule,and rates included in Exhibit
A. The maximum compensation includes all costs, expenses and reimbursements and will remain in
place even if Contractor's actual costs exceed the capped amount.Contractor must submit invoices and
the information required in Exhibit A in order to receive payment. City will compensate Contractor
within 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
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
Recreation Services Agreement/Rev. 3-27-2018
Page 1 of 7
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. 3-27-2018
Page 2 of 7
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. Contractor 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.html).
D. Submit required forms and acknowledgments included in Exhibit D, and ensure its each
participant is provided with a concussion information sheet, signs and returns the forms to
the City as required by Health and Safety Code Section 124235.
Require coaches and administrators to successfully complete the concussion and head injury
education at least once either online or in person, before supervising a participant.
Contractor shall offer training, educational materials, or both to each Contractor
administrator on a yearly basis. (Training resources are available at the Center for Disease
Control&Prevention(link cited above).
E. If providing instruction, Contractor must acknowledge and comply with all requirements
set forth in the Recreation&Community Services Instructor Manual.
Check one (if applicable):
® This contract requires services for children.
Recreation Services Agreement/Rev. 3-27-2018
Page 3 of 7
❑ This contract currently does not require services for children. If in the future, services
for children are required, the contract will require a'written amendment' to include the
appropriate insurance coverages as required in'Exhibit B-Insurance Requirements for
Recreation Contracts', proof of finger printing and additional requirements under
Paragraph 13. The contract amendment will also require the approval of the Director of
Recreation and Community Services and City Attorney.
14. Coordination of Services. The Parties designate the following persons as Services
Coordinators with the responsibility to oversee the delivery of Services in accordance with the terms of
this Agreement. Contractor's designation and any substitution are subject to City approval.
For City: For Contractor:
Name: Colleen Ferris Name: SA-AD KONGBOON
Position: Recreation Coordinator Position:FITNESS INSTRUCTOR
Contact: colleenf@cupertino.org 408-777-3160 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
Recreation Services Agreement/Rev. 3-27-2018
Page 4 of 7
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.
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
cc: Representative/Coordinator: cc: Representative/Coordinator:
Colleen Ferris SA-AD KONGBOON
Email: colleenf@cupertino.org Email:
27. Validity of Contract. This contract is valid and enforceable only if it complies with the
provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or
authorized designee, and is approved for form by the City Attorney's Office.
28. Execution. The person executing this contract on behalf of Contractor represents and
warrants that Contractor has full right, power, and authority to execute this contract and to carry out
all actions and services required. This contract constitutes a legally binding obligation of Contractor,
and may be executed in counterparts, each one of which is deemed an original and all of which, taken
together, constitute a single binding instrument.
Recreation Services Agreement/Rev. 3-27-2018
Page 5 of 7
IN WITNESS WHEREOF,the parties have caused this contract to be executed.
CONTRACTOR CITY OF CUPERTINO
SA-AD KONGBOON A Municipal Cor oration
By 4 � By
Name A--P0 1KON&6Q0 iv Name Christine Hanel
Title q06-0- u&'3{,\y eTQ P Title Assistant Director of Recreation&Community Services
Date 5/ (0 LAO I C� Date
Tax I.D. No.: P r / V q
APPROVED AS TO FORM: ATTEST:
S ZI l�
RAND LPH STEVENSON HOM GRACE SCHMIDT
Cupertino City Attorney City Clerk
Fiscal Year:2018-19 Fiscal Year:2019-20
ContractlEncumbered Amount:$2,500.00 ContractlEncumbered Amount:$2,500.00
Account No.:570 63 621 700 702 Account No.:570 63 621 700 702
Recreation Services Agreement/Rev. 3-27-2018
Page 6 of 7
EXHIBIT A
SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide FITNESS INSTRUCTION in,but not limited to,the
following:
YOGA
Location and Time of CONTRACTOR Services:
Refer to the MONTHLY FITNESS CLASS SCHEDULE 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: $42/class. The total compensation to the Contractor shall not exceed
$5,000.00.
Eligible Participant Minimum and Maximums for CONTRACTOR Services:
Minimum: 10
Maximum: 50
If less than the required minimum number of participants enroll in and pay for a particular class as
identified in the schedule before the class is scheduled to start, the City may cancel the particular class
and/or terminate this Agreement without additional notice or payment to Contractor.
List of all Contractor Employees working for the City of Cupertino (if no Employees,identify
"self'):
self
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.
Exhibit B
Insurance Requirements for Recreation Contracts
As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance
for the duration of the contract against claims arising from or in connection with Contractor, its agents,
representatives, employees or subcontractors Services under this Agreement.
Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as:
1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an
"occurrence" basis, including property damage, bodily injury and personal & advertising injury with
limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply
separately to this project/location(CG 25 03 or 25 04)or be twice the required occurrence limit.
2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos,
Code 8 (hired) and 9 (non-owned), with limits no less than $1,000,000 per accident for bodily injury and
property damage.
❑ Required if automobile is used to perform work under this contract.
Otherwise, proof of Contractor's personal auto insurance with limits required by state law
suffices. Contractor shall not transport or use its personal vehicle to transport participants or
perform work under this contract.
3. Workers' Compensation: As required by the State of California, with Statutory and Employer's
Liability Insurance limits of no less than $1,000,000 per accident for bodily injury or disease.
❑ Required if Contractor has employees.
If no employees, Contractor must sign Affidavit of No Employees.
4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/services involving
minors, (i.e., after school activities, recreational programs, athletics, study/training events and
transportation of minors). Coverage may be included under General Liability or be obtained in a separate
policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per
occurrence. If a general aggregate limit applies, it must apply separately to this contract or be twice the
required occurrence limit.
Required if Contract involves services to children.
Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance.
Self-Insured Retentions: Self-insured retentions must be approved by City. City may require Contractor to
provide proof of ability to pay losses and related investigations, claim administration, and defense
expenses within the retention. The policy language must provide, or be endorsed to provide, that the self-
insured retention may be satisfied by either the named insured or City.
Acceptability oflnsurers: Insurance must be issued by insurers acceptable to City and licensed to do business
in the State of California,with an A.M. Best's financial strength rating of"A"or better and a financial size
rating of"VII"or better.
OTHER INSURANCE PROVISIONS: The CGL policy must contain, or be endorsed to contain, the
following provisions:
1. The City, its City Council, boards and commissions, officers, officials, employees, agents, servants
and volunteers are to be covered as additional insureds with respect to liability arising out of work or
Exh. B Insurance for Recreation Contracts Updated 3-26-18
1
operations performed by or on behalf of the Contractor including materials, parts or equipment
furnished in connection with such work or operations.
2. Contractor's insurance shall be primary insurance coverage at least as broad as ISO CG 20 01 04
13 as respects the City, its officers, officials, employees, agents, and volunteers.
3. The Insurance Company agrees to waive all rights of subrogation against the City, its elected or
appointed officers, officials, agents, and employees for losses paid under the terms of any policy
which arise from work performed by Contractor for City. This provision also applies to the
Contractor's Workers' Compensation policy.
4. Each insurance policy required by this contract shall provide that coverage shall not be canceled,
except with notice to the City.
Primary Coverage: The Additional Insured coverage under Contractor's policy shall be primary non-
contributory and at least as broad as ISO CG 20 01 04 13 as respects the City and all the
insureds/indemnitees. If the limits of insurance required are satisfied in part by Umbrella/Excess Insurance,
the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall
also apply on a "primary and non-contributory" basis for the benefit of the Additional Insureds before City's
own insurance is triggered.
Notice of Cancellation: Each insurance policy shall provide that coverage shall not be canceled or allowed to
expire without written notice to City 30 days in advance or 10 days in advance if due to non-payment of
premiums. Such notice must be sent to City via email or certified mail to the attention of the City Manager.
Waiver of Subrogation: Contractor grants City a waiver of any right to subrogation which any insurer of said
Contractor may acquire against City by virtue of payment of any loss under such insurance. Contractor will
obtain any endorsement that may be necessary to effect this waiver of subrogation, but this provision applies
regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer.
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.At a minimum Contractor must provide acceptable copies of the policy
declarations and endorsement page verifying the required insurance coverages.
Homeowner's Insurance: 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 City.
Special Events Coverage:Insurers may provide special events coverage for a reduced fee, or City may be
able to offer this coverage. Contractor should contact the City Manager's Office for information or assistance.
Special Risks or Circumstances:City reserves the right to modify these requirements based on the nature of
the risk, prior experience, insurer, coverage, or other special circumstances.
Exh. B Insurance for Recreation Contracts Updated 3-26-18
2
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 Sa-ad Kon bg oon.
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 qday of in `� 2018, at California.
Sf,-A-D K 0
PRINT NAME
4
SIGNATURE
EXHIBIT D
Contractor's Mandated Reporter Declaration
The undersigned does hereby certify that:
1. I am a representative of Sa-ad Kongboon; that I am familiar with the facts herein and am
authorized and qualified to execute this declaration.
2. I declare that Sa-ad Kongboon has complied with fingerprinting and criminal background
investigation requirements with respect to all Contractor's employees who may have
contact with minors in the course of providing services pursuant to the Agreement, and
the California Department of Justice has determined that none of those employees has
been convicted of a felony, as that term is defined in California Penal Code Section
11105.3.
3. I declare that each coach and administrator shall be required to successfully complete
concussion and head injury education at least once, either online or in person, before
supervising a participant, as required by California Health and Safety Code Section
124235, et seq.
4. On a yearly basis, all participants shall be required to sign and return a concussion and
head injury information sheet in compliance with California Health and Safety Code
Section 124235, which may be in the form attached as D-1.
5. That a complete and accurate list of Contractor's employees, who may come in contact
with minors during the course and scope of the Agreement, are included below.
6. All of the below mentioned employees have tested negative for TB, or X-ray results for
TB, and have current documentation on file with Contractor.
7. All of the below mentioned employees have received training and understand their
responsibilities under the Mandated Reporter laws of this state and are willing and able to
comply.
List of all Contractor Employees working for the City (if no Employees,identify "self"):
Sri ,
S. The Contractor will notify the City of Cupertino in writing of any new employees and
will be added to the above list prior to beginning work at the City of Cupertino.
I declare under penalty of perjury that the foregoing is true and correct.
Sa-ad Kongboon
By: Sa-ad Kongboon
Title: FITNESS INSTRUCTOR
Date: 5 / 10 0
ACbR" CERTIFICATE OF LIABILITY INSURANCE DAT5/15/2D/YYYY)
05/15/2018
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(les) 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
K&K Insurance Group, Inc. P CNE 1-800-506-4856 FAX 1-260-459-5590
A/C No Et),. A/C No:
1712 Magnavox Way E-MAIL info@fitnessinsurance-kk.com
Wayne IN 46804 ADDRESS: nfo@fitnessinsurance kk.com
PRODUCER
CUSTOMER to:
INSURERS AFFORDING COVERAGE NAIC#
INSURED 2000991345 CP#5850 INSURER A: Nationwide Mutual Insurance Company 23787
Sa-ad Kongboon INSURER B:
INSURER D:
A Member of the Sports,Leisure&Entertainment RPG INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2000361475 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.
INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMBS
LTR INSD WVD MM/DD MM/DD/Y
A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006255600 06/15/18 06/15/20 EACH OCCURRENCE $1,000,000
12:01 AM 12:01 AMDAMAGE TO RENTED $1,000,000
CLAIMS-MADE❑X OCCUR PREMISES Ea Occurrence
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE per year$5,000,000
POLICY F—]PROJECT❑LOC PRODUCTS-COMP/OP AGG per year$1,000,000
OTHER: PROFESSIONAL LIABILITY $1,000,000
LEGAL LIAB TO PARTICIPANTS $1,000,000
AUTOMOBILE LIABILITY COMBINED SI L LI Ea
accident
ANY AUTO BODILY INJURY(Per person)
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident)
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident
X Not provided while in Hawaii
UMBRELLA
UAB OCCUR EACH OCCURRENCE
EXCESS LIAB RCLAIMS-MADE AGGREGATE
DED RETENTION
WORKERS COMPENSATION N/A PER STATUTE OTHER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/ Y/N
E.L.EACH ACCIDENT
EXECUTIVE OFFICER/MEMBER
EXCLUDED?(Mandatory in NH) El E.L.DISEASE—EA EMPLOYEE
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE—POLICY LIMIT
MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL
EXCESS MEDICAL
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certified Instructor of:Yoga
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.
This certificate voids and replaces certificate#W01211649
Abuse,Molestation,Harassment or Sexual Conduct Defense Cost Reimbursement-$100,000
CERTIFICATE HOLDER CANCELLATION
City of Cupertino,its City Council,Boards and Commissions,Officers, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Officials,Employees,Agents,Servants,Volunteers and Consultants EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
10300 Torre Avenue THE POLICY PROVISIONS.
Cupertino,CA 95014
Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
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(2016/03) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 6BRPG0000006255600 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 and Commissions, Officers,
Officials, Employees, Agents, Servants, Volunteers and Consultants
10300 Torre Avenue
Cupertino, CA 95014
Named Insured: Sa-ad Kongboon
CP#5850
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II—Who Is An Insured is amended to include as an B. With respect to the insurance afforded to these additional insureds,
additional insured the person(s)or organization(s)shown in the the following is added to Section III—Limits Of Insurance:
Schedule,but only with respect to liability for"bodily injury", If coverage provided to the additional insured is required by a
"property damage"or"personal and advertising injury"caused,in contract or agreement,the most we will pay on behalf of the
whole or in part,by your acts or omissions or the acts or omissions additional insured is the amount of insurance:
of those acting on your behalf:
1. In the performance of your ongoing operations;or 1. Required by the contract or agreement;or
2. In connection with your premises owned by or rented to you. 2. Available under the applicable Limits of Insurance shown inthe Declarations;
However: whichever is less.
1. The insurance afforded to such additional insured only This endorsement shall not increase the applicable Limits of
applies to the extent permitted by law;and Insurance shown in the Declarations.
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 0 Insurance Services Office, Inc.,2012 Page 2 of 2
Amended auto policy declarations WAllstate,
Your policy effective date is December 20,2017 You're in good hands.
Page 1 of 4
Information as of November 9,2017
Total Amount Due for the Policy Period
Please review your insured vehicles and verify their VINs are correct. Summary
Vehicles covered Identification Number(VIN) Premium Named Insured(s)
Policy number
*Your bill will be mailed separately.Before making a payment,please refer to your
latest bill,which includes payment options and installment fee information.If you do Your policy provided by
not pay in full,you will be charged an installment fee(s). Allstate Northbrook Indemnity
Company
Discounts (included in your total premium) Policy period
Beginning December 20,2017 through
Anti-theft $1.26 Good Driver(20%) $146.35 June 20,2018 at 12:01 a.m.standard
Multiple Policy $11.59 Distinguished $122.03 time
Driver Your policy changes are effective
Total discounts $281.23) December 20,2017
Your Allstate agency is
David N Gragnola
Discounts per vehicle 10520 S. De Anza#B
Cupertino CA 95014
$108.97 (408)252-3830
Anti-theft $.48 Good Driver(20%) $56.81 davidgragnola@allstate.com
Multiple Policy $4.45 Distinguished $47.23
Driver Some or all of the information on your
Policy Declarations is used in the rating
$172.26 of your policy or it could affect your
Anti-theft $.78 Good Driver(20%) $89.54 eligibility for certain coverages.Please
Multiple Policy $7.14 Distinguished $74.80 notify us immediately if you believe that
Driver any information on your Policy
Declarations is incorrect.We will make
Listed drivers on your policy corrections once you have notified us,
Sa Ad Kongboon and any resulting rate adjustments,will
be made only for the current policy
period or for future policy periods.
Please also notify us immediately if you
Excluded drivers from your policy believe any coverages are not listed or
None are inaccurately listed.
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Amended auto policy declarations Page 2 of 4
Policy number:
Policy effective date: December 20,2017
Coverage detail for
Coverage Limits Deductible Premium
Automobile Liability Insurance Not applicable $178.24
Bodily Injury $500,000 each person
$500,000 each occurrence
mr
Property Damage $100,000 each occurrence
WW
Auto Collision Insurance Actual cash value $1,000 $76.71
Waiver of deductible applies
Auto Comprehensive Insurance Actual cash value $0 $9.14
S.' Rental Reimbursement Not purchased*
IZWW
Q L Towing and Labor Costs Not purchased*
Uninsured Motorists Insurance for Bodily $500,000 each person Not applicable $29.48
Injury $500,000 each accident
Automobile Medical Payments Not purchased*
Coordinated Medical Protection Not purchased*
Lease/Loan Gap Not purchased*
Repair or Replacement Cost Option Not purchased*
® Sound System Not purchased*
Tape Not purchased*
Total premium for $293.57
*This coverage can provide you with valuable protection. To help you stay
current with your insurance needs,contact your Allstate agent to discuss
coverage options and other products and services that can help protect you.
VIN Rating information
Your premium is determined based on certain information,
including the following:
• This vehicle is driven 3-9 miles to work/school,married male
licensed 53 years.
Allstate uses mileage information as one factor to help determine your premium amount. a
V
Important Note:The annual mileage figure applicable to this vehicle for the expiring policy period was:1,500-1,999.The
annual mileage figure applicable to this vehicle for the current policy period is:1,500-1,999. o
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The following odometer information was used to determine your annual mileage for current policy period: o
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Odometer Reading:39,686 Odometer Reading:42,259 m
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Date:08/07/2015 Date:02/27/2017 0
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If any of the information shown above is incorrect,missing or changes in the future,please contact your Allstate o
representative.Please keep in mind that a change in any of the information may result in an adjustment to your premium. o
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Amended auto policy declarations
Policy number: Page 3 of 4 Q)Allstate.
Policy effective date: December 20,2017
You're in good hands,
Coverage detail for
Coverage Limits Deductible Premium
Automobile Liability Insurance Not applicable $171.22
Bodily Injury $500,000 each person
$500,000 each occurrence
Property Damage $100,000 each occurrence
WAuto Collision Insurance Actual cash value $1,000 $121.90
Waiver of deductible applies
Cgp Auto Comprehensive Insurance Actual cash value $0 $14.85
9' Rental Reimbursement Not purchased*
z Towing and Labor Costs Not purchased*
Uninsured Motorists Insurance for Bodily $500,000 each person Not applicable $50.17
Injury $500,000 each accident
AgO Automobile Medical Payments Not purchased*
Coordinated Medical Protection Not purchased*
Lease/Loan Gap Not purchased*
Repair or Replacement Cost Option Not purchased*
Sound System Not purchased*
Tape Not purchased*
Total premium for $358.14
*This coverage can provide you with valuable protection. To help you stay
current with your insurance needs,contact your Allstate agent to discuss
coverage options and other products and services that can help protect you.
VIN Rating information
Your premium is determined based on certain information,
including the following:
• This vehicle is driven for pleasure,married female licensed 53
years.
Allstate uses mileage information as one factor to help determine your premium amount.
Important Note:The annual mileage figure applicable to this vehicle for the expiring policy period was:9,500-9,999.The
annual mileage figure applicable to this vehicle for the current policy period is:9,500-9,999.
The required odometer information to calculate your annual mileage for the current policy period was not provided,was
illegible,could not be obtained or the most recent odometer reading we received was less than a previous reading.
If any of the information shown above is incorrect,missing or changes in the future,please contact your Allstate
representative.Please keep in mind that a change in any of the information may result in an adjustment to your premium.
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Amended auto policy declarations Page 4 of 4
Policy number:
Policy effective date: December 20,2017
Additional coverages
Coverage Limits
Automobile Death Indemnity Insurance Not purchased*
Automobile Disability Income Protection Not purchased*
Identity Theft Expenses Not purchased*
*This coverage can provide you with valuable protection. To help you stay
current with your insurance needs,contact your Allstate agent to discuss
coverage options and other products and services that can help protect you.
Your policy documents
Your automobile policy consists of this Policy Declarations and the documents in the following list.Please keep these together.
• Allstate Automobile Policy-AU104-3 California Amendatory Endorsement-AU14629-2
• Amendment of Policy Provisions-AU14626-1
Important payment and coverage information
Here is some additional,helpful information related to your coverage and paying your bill:
►Your rate is lower because you are insuring multiple cars.
Allstate Northbrook Indemnity Company's Secretary and President have signed this policy with legal authority at Northbrook,
Illinois.
Steven P.Sorenson Susan L. Lees
President Secretary
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ARCH 401t
INTERMEDIARIES
CLAIMS MADE SEXUAL MISCONDUCT AND MOLESTATION INSURANCE
Form: SML Safeguard Wording- 623AFB00213
Policy Number: TBA
Renewal of: N/A
Named Insured: City of Cupertino—Dept of Recreation&Community Services
Principal Address: 10185 N Stelling Road, Cupertino, CA, 95014
Policy Period: From: 1"July 2018 To: 1"July 2019
Both dates at 12:01 a.m.Local Time at the Principal Address stated in Item 1.
Limit of Liability:
a) USD 5,000,000 for all Claims for Wrongful Acts against any one Victim
b) USD 5,000,000 for all Claims for Wrongful Acts against all Victims,but
sub-limited to:
c) USD 50,000 for all Safeguard Costs resulting from all Circumstances
Such Sub-limit of Liability shall be part of, and not in addition to,the overall Limit of Liability
stated in 3.b)above.
Retention:
USD 35,000 any one Victim
Premium:
USD 27,000 to be paid within 25 days of attachment
Notification pursuant to Clause IX. shall be given to:
Claims Department Beazley
30 Batterson Park Road,
Farmington,
CT 06032.
claims@-beazley.co
(860) 677 3765 (phone)
(860)679 0247 (fax)
Retroactive Date:
Pt July 2018
Pending or Prior Litigation Date:
I`July 2018
Service of Suit:
Eileen Ridley,FLWA Service Corp.,c/o Foley&Lardner LLP,
555 California Street, Suite 1700, San Francisco, CA 94104-1520
Choice of Law:
New York
Conditions:
Application Dated: TBA
California Surplus Lines Notice 1-LMA9098A
Small Additional or Return Premiums Clause(U.S.A.)—NMA 1168
Nuclear Incident Exclusion Clause-Liability-Direct—NMA 1256
Radioactive Contamination Exclusion Clause-Liability-NMA 1477
War and Terrorism Exclusion—NMA 2918
Sanctions Limits Clause-LMA 3100
Beazley Safeguard Education Document
Arch Safeguard Enhancement Endorsement
U.S Classification:
Surplus Lines Broker and State filed in: TBA
License Number: TBA
Subject to:
1) Satisfactory re-signed and dated SML application within 30 days of inception
2)Confirmation of the Surplus Lines Broker.Including name of individual, company
name,address and license number
All subj ectivities to be received within 7 working days of binding otherwise Underwriters
reserve the right to amend terms or cancel ab initio.
Brokerage: 22.5%or same net equivalent downwards,plus taxes as applicable
Information: Employees—36 full time+250 part time+63 IC's
Exposure Units—97,000
Nature of Business—Municipality
Cancellation by an Insured may result in a short rate calculation to determine
the return premium, subject to 5%minimum earned of the total premium.
Underwriting
Security: 100%Lloyd's(Inforination about Lloyds)