18-001 Mau Truong CITY OF
No.
FY 2018-20
CUPERTINO
RECREATION SERVICES AGREEli�IENT
Parties. This contract is made atld entered into as of 9/8/2018 ("Effective Date'), by and between the
City of Cupertuzo, a municipal corporation ("City"), and with MAU TRUONG, ,
Milpitas, CA 95035 ("Contractor"), a SOLE PROPRIETOR for ADULT FITNESS INSTRUCTION.
1. Services. Contractor agrees to provide the Services included u1 the Scope of Work and
in accordance wit11 the Schedule of Performance attaclled in Exhibit A.
2. Term. This contract beguzs on the Effective Date and ends on 6/30/2020 ("Contract
Tirne"),unless extended or terminated as provided herein. Time is of the essence and Contractor inust
11ave sufficient time, resources, and qualified staff to deliver t11e Services as required. Contractor must
promptly notify City of any actual or potential delays to afford the Parties adequate opporttuZity to
address or mitigate such delays.
3. Cornpensation. City will pay Contractor for satisfactory perforinance of the Services an
amount that will based upon actual costs but that will be capped so as not to exceed$10,000("Contract
Price"),based upon the Scope of Services,budget,perforinance schedule, and rates uzcluded in Exhibit
A. The maximum compensation includes all costs, expenses and reiinburseinents and will remain in
place even if Contractor's actual costs exceed the capped amount.Contractor must submit uzvoices and
the ulformation required in Exhibit A in order to receive payment. Cify will compensate Contractor
within 30 days after approval of written ulvoices.
Invoices are subject to review and audit by City durulg regular business hours upon 24-hours'
notice. Conixactor inust maultain coinplete and accurate records of payrolls, expenditures,
disbursements and other cost items charged to City or establishing the basis for an invoice, for a
muzimum of four (4)years from the date of final payment.
4. Independent Contractor..Contractor is an independent Contractor and not an employee,
partner, or joint venture of City. Contractor is solely responsible for t11e rneans and methods of
performing the Services and for the persons hired to work under this Agreeinent.No civil service status
or otller right of einployment 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 otller benefit.
Contractor must have the skills and qualifications to perform the Services in a competent and
professional manner. Contractor will supply all tools, materials atld equipment required to perform
the Services under this Contract. Contractor is responsible for obtaining permits and licenses required
by law and inust obtain a City busuless license.
Rec��eation Services Agreement/Rev. 3-27-2018
Page 1 of 6
5. Proprietary/Confidential Inforrnation. To the extent Conhactor 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
of care to protect City ulformation as a reasonably prudent Contractor would use to protect its own
proprietary data.
6. Ownership of Materials. To the extent Contractor prepares written material, drawulgs
or data u1 corulection wit11 t11is contract, City will have the property rights to those inaterials and all
copyrights,if any, to such work product will constitute City property.
7. Records. Contracfor must maintain complete,accurate, and detailed accountulg records
relating to its performa�zce in accordance with generally accepted accountulg principles and
procedures. Tl1e records must include detailed information about Contractor's services, benchinarks,
deliverables and costs/fees,and inust be made reasonably available fo City.The records and supporting
docuinents must be kept separate froin otller files and inavzfained for four years from the date of City's
final payment.
8. 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 fllose
persons wllose names are included 'u1 Exhibit A inay perform t11e Services.
9. Publicity and Signs. Any publicify generated by Contractor related to this contract or
the Services during the Contract Tiine a�zd for one year thereafter must reference City contributions.
The words "City of Cupertulo" shall be displayed u1 all pieces of publicity, including flyers, press
releases, posters, brochures, public service announcements, ulterviews and newspaper articles. No
signs may be posted,exhibited or displayed on or about City property, except signage required by Iaw
or under this Agreement without prior written approval from City.
10. Indernnification. To the fullest extent allowed by law and except for losses caused by
the sole negligence or wi11fu1 misconduct of City personnel, Contractor agrees to uldeinnify, defend,
and hold harmless t11e City, its City Cotuzcil, boards and commissions, officers, officials, einployees,
agents, servants, volunteers and Contractors (collectively, "Indei�nnitees"), through legal counsel
acceptable to City, from and agauzst 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, adrninistrative and regulatory proceedulgs), of every nature, arising out of or
in any way related to Contractor's or Contractor's agents performance of t11is contract or the Seivices.
This includes but is not liinited to Liability resulting v1 personal injury, death, property dainage, or
econoinic losses. Contractor must pay any costs City may incur u1 enforcing this provision and rnust
accept a tender of defense upon receiving notice froin City. Contractor's payments inay be deducted or
offset to cover any money the City lost due to a claim or counterclaiin arisuzg out of this Contract.
11. Insurance. Contractor shall comply with the insurance requireinents in Exhibit B. City
will not execute the Agreeinent until it 11as received and approved satisfactory certificates of insurance
and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole
discretion inay purcllase ulsurance and deduct t11e costs froin payments to Contractor,or terini�zate the
contract.
Rec�^eation Sei-vices Agreement/Rev. 3-27-2018
Page 2 of 6
12. Compliance with Laws and Other City Requirements.
Requirernents for all Contracts. This contract is subject to local, state and federal laws and
regulations prolzibitulg discriinination,includulg Title VII of the Civil Rights Act of 1964,the California
Fair Elnployment Practices Act,the Ainericans with Disabilities Act of 1990,and other laws that pertain
to fair employment atld anti-discrirnuzation practices. Contractor inust comply wit11 labor laws
pertainuzg to prevailitlg wages, working hours, overtime, payroll records, a�1d other requireinents
irnposed by t11e Department of I�ldustrial 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 ulterest laws and regulations applicable to this Agreernent and
avoid conflicts of interesf. Contractor inay be required to file a conflict of interest form for engagulg in
goverrunental decisions or serving in a staff capacity,and is hereby advised to review the requireinenfs
of California Political Reform Act and the California Code of Regulations. Services inay only be
performed by persons who are not einployed by City and who do not have a contractual relationsllip
with City other than this contract. Contractor agrees to abide by City policies and adlnulistrative 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 fulgerprinting and a criminal background check and verify all employees
providing services wlder this contract have met this requirement.
B. Coinplete 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 fiom
play, and return to play protocols. (Refer to Center for Disease Control & Prevention,
htt�s://www.cdc.gov/head su�/index.html�.
D. Submit required forms and aclalowledgments included u1 Exhibit D, and ensure its each
participant is provided with a concussion inforination sheet, signs a�1d reiurns the forms to
t11e 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 s11a11 offer trauzing, educational inaterials, or both to each Contractor
adininistrator on a yearly basis. (Trainuzg resources are available at the Cenfer for Disease
Control&Prevention(lulk cited above).
E. If providing ulstruction, Contractor must acicnowledge and comply with alI requirements
set fortll it1 the Recreation&Coinmunity Services Instructor Mailual.
Checl<one (if applicable):
❑ T11is contract requires services for children.
Reci^eation Services Agreement/Rev. 3-27-2018
Page 3 of 6
� This contract currently does not require services for children. If i�z the future, services
for children are required,the contract will require a'written amendinent' to ulclude flze
appropriate i�zsurance coverages as required u1'Exhibit B-Insurance Requirements for
Recreation Coniracts', proof of fulger printing and additional requirements under
Paragraph 13. The contract amendment will also requue the approval of t11e Director of
Recreation and Cominunity Services and City Attorney.
14. Coordination of Services. The Parties designate the followuzg persons as Services
Coordinators with the responsibility to oversee the delivery of Services in accordance with fihe terms of
this Agreement. Contractor's designation and any substitution are subject to City approval.
For City: For Contractor:
Naine:Karen Levy Name:Mau Truong
Position: Recreation Coordulator Position:Adult Fit�less Instructor
Contact:karenl@cut�ertulo.org;408-777-3123 Contact:
15. Abanc�onment. 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 t11e
date of abaYldorunent upon submission of final invoices approved by City.
16. Termination. City inay terminate fllis contract for cause or witlzout cause at any time
a�1d will notify Contractor as soon as possible. Contractor will be paid for satisfactory services rendered
through the date of termination upon subinission 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 proceedulgs filed against City u1 connection with t11is
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 Califonlia. 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 findulgs of law and fact.
18. Attorney Fees. If City is required to pursue litigation,arbitration or other adminisfrative
or regulatory proceedulg 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 payrnent tliereof 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, whetller of the same or a different character.
21. Entire Agreement. This Agreement atld all referenced Exhibits are hereby attached and
uzcorporated ulto the Agreeinent by this reference aizd represent the full and complete understanding
as to those inatters contained herein, and supersede a�1y other contract or understanding,eifller oral or
Rec��eation ServicesAgreenzent/Rev. 3-27-2018
Page 4 of 6
written,between the Parties.This Agreeinent may not be modified or ainended except in writing signed
by both Parties.If there is any iticonsistency between the inain contract and atly attachments or exhibits
tllereto, tlle inain contract shall prevail.
22. Inserted Provisions.Each provision or clause required by law or flzis contract is deeined
to be included and will be ulferred herein. Eitller party may request an amendmellt to cure any
mistaken ulsertion or omission of a required provision.
23. Headings. The headings are for convenience only and are not a part of t11e conhact or
intellded to affect, limit or amplify the terins or provisions of this Agreelnent.
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 tenn or
provision s11all reinain in force and effect to the extent allowed by suc11 ruling.All other contract terins
a�1d provisions and their application to specific situations will relnain in full force and effect.
25. Survival.All provisions which by their nature must continue after t11e Agreeinent ends,
including without limitation Indemnification, Insurance, Ownership of Materials, Records, Governing
Law and Attorney Fees,will survive the expiration or termuzation of this Agreement.
26. Notices.All notices and itlstruments pertaining to material provisions of this contract or
significant disputes which are required by law or utlder this contract to be in writuzg must be sent to
� the persons listed below. T`he notices will be deemed effective on tlle date of personal delivery or t11e
date confirmed by a reputable overnigllt delivery service, on the fifth calendar day after deposit in the
United States Mail, postage prepaid, registered or certified, or the next busuless day following
electronic submission.
To City of Cupertuzo: To Contractor:
Office of the City Manager , Milpitas, CA 95035
10300 Torre Ave., Cupertino CA 95014
cc: Representative/Coordi�zator: cc:Representative/Coord"uzator:
Karen Levy Mau Truong
Einail: karenl@cupertulo.org Email:
27. Validity of Contract. This contract is valid and enforceable only if it complies wit11 the
provisions of Cupertulo Mtulicipal Code Chapteis 3.22 a�1d 3,23, is signed by fl1e City Manager or
authorized designee, and is approved for forin Uy the City Attorney's Office.
28. Execution. The person executitlg tllis contract on behalf of Contractor represents and
warrants that Contractor has full right, power, a�1d authority to execute this contract and to carry out
all actions and services required. This contracf constittztes a legally binding obligation of Colltractor,
and may be executed in counterparts, each one of whicll is deemed an original and all of whicll, taken
togetller, constitute a sulgle binding instrulnent.
Recf•eation Services AgreeTnent/Rev. 3-27-2018
Page 5 of 6
IN WITNESS WHEREOF,the parties have caused this colztract to be executed.
CONTRACTOR CITY OF CUPERTINO
Mau Truong A Mtulicipal Corporation
B �.� � By �,����.�-�--��
d. ���
Name L� Name�.rY1�1�1'aC.- ��--I
Title Title �7�� J/e��-��°�'�
Date �� �� -�'�� Date �3u'"7 c�"
Tax I.D. No.: refe��to W-9 on file
APPROVED AS TO FORM: ATTEST:
� ��/� ��Z,���'
�- ��' ��` ;� �- i � � `
, /�� , �
OC O V. FIERRO GRACE SCHMIDT
Cu rtino Actulg City Attorney City Clerk �� � ��
FY 18-19
ContractlEncumbered Amount: $5000
Account No.:580-63-620 700-702
FY 19-20
ContractlEncuanbered Amount: $5000
Account No.:580-63-620 700-702
Recreation Services Agreei�zent/Rev. 3-27-2018
Page 6 of 6
EXHIBIT A
SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide ADULT FITNESS INSTRUCTION in,but not limited to,the following:
THERAPEUTIC STRETCHING&BREATHING, THERAPEUTIC BREATHING METHODS
Location and Time of CONTRACTOR Services:
Refer to the Recreation Schedule dated SUMMER 2018-SPRING 2020 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 perforined pursuant to this Agreement.Compensation shall
consist of the following: 65%of resident fees&passes. The total coinpensation to the Contractor shall not exceed
$10,000. (FY18-19=$5000;FY19-20=$5000).
Eligible Participant Minimum and Maxirnurns for CONTRACTOR Services:
Minimum: 5
Maximum: 20
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 terininate 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 sclledule.Participants may not tal�e 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 reinain 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 subinitted to the City within
24 hours of t11e injury occurring.
'Exhibit B
IlZSl[Pance Req:ui��e»2ents fo�°Rec�•eatio�t Coz2t��acts
As required by Section 12 of the Agreement, Contractor shall procure aild maintain the following insurance
for the duration of the contract against clainls arising from or ui comlection with Contractor, its agents,
representatives, employees or subcontractors Services under tlus Agreeinent.
Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as:
L Commercial General Liability (CGL): I�Zsurance Seivices Office I'oinl CG 00 Ol covering CGL on an
"occui�ence" basis, including property damage, bodily injury and personal & advertising injuiy with
limits no less than $1,000,000 per occuirence. If a general aggregate linzit applies, it i�lust apply
separately to this project/location(CG 25 03 or 25 04) or be twice the required occurreilce luzlit.
2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos,
Code 8 (lui•ed) and 9 (non-owned), with liinits no less than$1,000,000 per accident for bodily injuiy and
property damage.
❑ Requi�ed f auto»iobile is used to�erfo�°m wo��k u��deN this co�at��act.
� Otlief-�vise, ��°oof of Contracto�^'s �ersonal auto insui�c���.ce witlz li»�.its �°equi��ecl by state law
suffices. Coizt��actor sl�all �zot tNa�zs�o��t o��use its pefso�a.al vel�icle to tra��spo��t partici�a�zts o��
�e�for»z�voi�k u�2de�°tlais co�ztr�act.
3. Workers' Compensation: As required by the State of Califoi7iia, with Statutory and Employer's
Liavility I�7surance limits of no less than$1,000,000 per accident for Uodily injury or disease.
❑ Requi��ed if Co�ztracto�I�as ei�zployees.
fQ' If no e�nployees, Cont��acto�^�nust sig�Z Afficiczvit of No E»aployees.
4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/services involving
minors, (i.e., after school activities, recreational programs, atl�letics, study/ti•ainulg events and
transpoi-tation of minors). Coverage may be included under General Liability or be obtained iiz a separate
policy, such as Educators Legal Liability (ELL) policy, with a liinit of no less than $1,000,000 per
occui�ence. If a general aggregate linut applies, it must apply separately to tlus contract or be twice the
required occurrence limit.
❑ Requi�-ed if Corzt��c�ct involves sei��ices to chiZdi�erz.
Insurance coverage required n7ay be satis�ed by a combination of Prunary and Excess/Lhlzbrella ulsurance.
Self-Insu��ed Rete�itio��s: Self-insured retentions must be approved by City. City may require Contractor to
provide proof of ability to pay losses and related investigations, claun admiiustration, and defense
expenses witlun the retention. The �olicy language must pi•ovide, or Ue endorsed to provide, that the self-
insured retention may Ue satisfied by either the named insured or City.
Acceptability of Insur�ers: filsurance must be issued Uy insurers acceptaUle to City and licensed to do business
in the State of California,with an A.M. Best's financial strength i•ating of"A"or better and a financial size
rating of"VII"or better.
OTHER INSUI2ANCE PROVISIONS: The CGL policy must contain, or be endorsed to� contain, the
following provisions:
1. The City, its City Council, boards and conunissions, of�cers, officials, employees, agents, servants
and volunteers are to be covered as additional insureds with respect to liaUility arising out of work or
Ea�h,B Ii�sur•ance for^Recreatio�a ContJ•acts Updated 3-26-18
1
EXHIBIT C
AFFIDAVIT OF NO EMPLOYEES
State of California
County of Santa Cla��a
City of Cupertino
I, the undersigned, declare as follows:
I am an independent fitness instructor /l/,�i�/ ;T��l�j�'��'
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 Worl<ers' 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 worl<ing for
me or my business during the term of any service contract with the City of Cupertino. I am
not lequired to have Workers' Cornpensation 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�day of `� 2018, at � , California.
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,�c :��� Prui�ssidnalLi�ty+ #LRAFVTX17AOM � �,4�OD.oqt'tPer�sc�urr�ncelS3,IIiM3,�00�inus�'
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Holder named below is listed as an Additional Insured for the General Liability policy.
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City of Cupertino its City Council boards and �����������r���i��,�„����,�,�����������������������.����
commissions officers employees and volunteers 10300 7o req�����?'ri��A'r�xc�i.����a�:�i�nrrarw��r,�trr�a�iu�ro�,�c�sa���,�:;
Cupertino,CA 95014 t�������a���.r��ti�w c��a�.fa�n.tr�€�:�ar�r��ur��r���ra����as�rs nc��r�r��`
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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT
This endorseinent inodi�es insurance provided under the following:
COMMERCIAL GENERAL LIABILITY POLICY OCCURRENCE
HEALTH,WELLNESS &BEAUTY PROVIDERS PROFESSIONAL LIABILITY INSURANCE POLICY
I�l consideration of the premium charged, it is agreed that the defined term "I�siered" is hereby amended to include the following
person(s)and/or entity(ies):
1. The City of Cupertino, its City Council, boards and commissions, officers, officials, employees,
agents,servants and volunteers
ALL OTHER TERMS,CONDTTIONS AND EXCLUSIONS REMAIN UNCHANGED.
THIS ENDORSEMENT FORMS A PART OF POLICY N UMBER. LRAFVTX 17AOM
Issued by:Aspen Specialty Insurance Coinpairy
Issued to:Mau Tiuong
Effective date:2018-09-OS
ASPMT011 0118 2018 OAspen Insurance U.S. Services Inc. All rights reserved. Page 1 of 1
�/°� 1�/��� � '� r � �� , � � �-� - "
CSAA Insurance Exchange A►utomobile Policy Declarations
P.O.Box 22227
Insurance pakland,CA 94623-2221 Please keep with your policy.See Important Notice on reverse.
For questions or changes call:(800)922-8228
Page 1 of 1
7.Name and aodress of lnsured
I�h�ll�l��lll��ll'��I�I�'�I111"'ll��ll�6���10���1��y�01�n11� Z Oecfa�aticns Renewal Certificate v`°�tss
O �YPe oate 07-12'2017
� MAU N TRUONG ~
4 �0��`'� CAA52p1028599 ��sur�d
o f,�„
t� 12;01 A.M.kandard Time at the address of the
MILPITAS CA 95035-6662 � Named Insured,bu!not prior;o;he time applled
� voor 08-16-2017 �n�or,if this is a replacement declaretions,noe
V Po��q' pdor to the time coveraqe change was requested �
J Period
O rU
12 01 A.M.S;andard Time at the address of the
a 08-76-2018 NameAmwred.
A/ternare Address Octupa fron Alternate Numbe� THephone Number
Engineer/Scientist
l!em AAake MOUeI Yr 5ody 7�pe . Veh;c�e�dgnti,�caLbn No. � A'ame
W 1
w necessarity Sherry
Wy correspond
� p� �opimcipallv YUilg
� operateo
vehicles.
Coverage .................1labilityL:mils ltem 1 Item?
.................. .............................
....... �.... ......... .. ........ ":....
.............
ac Person Each qaurrence Ded cnble ; Prem�um Deduchble , Premmm Deduc6ble ; Prem�um peductible , vremium
Bodily injury 100,000 300,000 : � $184 , $136 < �� `�'
. ................................ ............... .......... ,. , ;
.... << :
Medica�Pa ments 5,000 • : � $33 ` ; $54
Y � ` :
; �,
..................................................... ......... .......� ...:.::� , ,
. >;;
Uninsured Motorists 100,000 300,000 % � $47 = . $57 ' �
.......................... ---.............. ..
Property Damage ' 100,000 ; $253 : $215
; ,
omprehensive Actual Cash Value Less Deductible � 250 : $70 250 �� $154 '' ' �
Full Comprehensive Sefety Glass Endorsement
--�-�-----�$0 deductible)---......--.......................................................... NQ COV i NO COV' � ;
Collision Actual Cash Value Less Deductible 500 � $284 500 ; $516 � `
... ...................---�--.......................................................... . , '
Enhanced Transporltation Expense �Z$ ; `
$25 per day/$750 aggregate $z$ ;� �"+
,:, ...:::. ... : _• ;
All Risks Actual Cash Value Less Deductible No Cov2rage No Co'verage
Vehicie Loan/Lease Protection Endorsement Nt�Eou2rage Na Ca�erage
New Car Added Protection Endorsement No�overage Na Coverage
driginal Equipment Manufacturer Parts(OEM)Endorsement '��1ti:Cov2rage No Cnverage
Ride-sharing Coverage Endorsement NoYCov2rage No Co'verage vz �
-,x� :��
TOTAL PREMIUM PER VEHICLE � $899 I ,$1,160
*Automobile Death Benefits $15,000 per deceased insured person Premrum
Premium Summary
This is not a bill.
CA Surcharge�$0
CA Special Fraud Assessment Fee:$3.52
Total Premium: $2,062.52
__._. _ _ _ .
Total Premium shown is for the Member AdvantageT""Program.
--_
-__ __._.
EXCLUSIONS "-"
There is no coverage provided by this Policy while the following individual(s)operate a motor vehide:
None
-- ___--_ _ _.._.... __ _
__ __ _
___ .___ _
Sc e ueo Changes -� - � -
�
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l7
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2
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55 1500 12 1 S
07.1Z�1017
05474
0219
(Continued on back)
Item Hafed Dnver Oriv Safefy kecord Yrs Driv Exp PriorAnn Miles Fut�;e Ann Miles Vpn Garage Zip uehicie Usage Gender Marital
u� 1 mau Truong 0 Pt 45 12,644 Mi 12,644 Mi 95035 Pleasure M M
a 2 0 Pt 12 10,000 Mi 70,000 Mi 95035 Commute F S See final page
Wfor explanation
�
of codes.
.,.
�
F-
� Discounts:
� Mature Driver:None. Multi Car:Item(s) i,2.
Good Driver:Item(s) 1,2. New Driver:None.
—p Multi Policy home condo:Item(s) 1,Z. Good Student:None.
WYou rnay quai�#y for ather"3prfld�rts''
Q , and°discaunts �or rr�ore::rrr�o caq::
N y�aUr(nsurance�gent
p ` Phtllip 6en�arrsin;
o; {44�)55'€4943.
_ . __
_ ,,_. .
IMPORTAN7 NOTICE:THIS IS A PART QF YOUR DECLARATIONS
� _ _._
;The insurance afforded is only with respect to such of the preceding coverages as are indicated by specific premium charge or charges.The :
;limit of the Exchange's liability under each such coverage shall be as stated herein,subject to all the terms of the policy.The purpose for
i which the automobile is to be used is pleasure or business,subject to the exclusions in the policy, including the exclusion far wholesale
and retail delivery.
'RENEWAL CERTIFICATE-Extends this policy for the period shown under Policy Period upon payment af the premium.
'AMENDED DECLARATIONS-In consideration of the premium adjustment indicated herein this policy is hereby amended only with respect '
to such changes as are indicated in the schedule of changes.The limit of the Exchange's liability under such amended eoverage shali be as
'stated herein.
LOSS PAYEE(S)-Any loss under Physical Damage coverages is payable as interest may appear to the named insured and the Loss Payee in
'accordance with the loss payable agreement.
� __ _
_ __ _. --. .
RATING INFQRMATION DISCLOSURE EXPLANATION
(From Discounts/Messages Section an Previous Page)
ITEM(ITEM NUMBER): Item number is the number assigned to the vehicle shown on the Declarations'
RATED DRIVER:The driver assigned to a vehicle whose attributes(e.g.,years driving experience, driving safety recard, gender,and marital
status)are used to develop the premium.
DRIV SAFETY RECORD(DRIVING SAFETY RECORD):The total number of points assessed the driver tor "principally at fault chargeable
accidents"with or without injury and/or vehicle code violation convictions(tickets).A "principally at fault chargeable accident"occurs
when the driver of a vehicle is at least 51%at fault for an accident and the total monetary damages(whether paid or not)in the accident
exceed:
• $750 ar the accident resulted in death fr�r!osses occur�ir�g prior to 12/1 T;1 i
° $1,000 ci the acc;dent resul,2d;n deaih`or lrss�s vccur;iny �2/11;ZC;1 cr after
Additional information on the number and types of incidents can be provided on request. Carriers use different point count systems for
rating purposes.The number of points shown on your declarations would not necessarily match the number of points assigned by
another carrier.
YRS DRIV EXP(YEARS DRIVING EXPERIENCE):The number of years a driver has been licensed to drive a motor vehiele anywhere in the
worid. However,a driver must have at least 18 months current driving experience in the United States, U.S:7erritories, or Canada, before
foreign country driving experience can be counted.
PRIOR ANN MILES(PRIOR ANNUAL MILES DRIVEN):The estimated number of total miles a vehicle was driven during the year just past,
FUTURE ANN MILES(fUTURE ANNUAL MILES DRIVEN):The estimated number of total miles a vehide will be driven in the coming year.
VEH GARAGE ZIP(VEHICLE GARAGED ZIP CODE):The ZIP code of the location where the vehicle is garaged.
VEHICLE USAGE:Vehicles are assigned to one of five usage designations: Business Use,Work Commute,Farm Use, Farm Business Use or
Pleasure.
GENbER: "M"stands for Male and "F°stands for Female.
MARITAL(MARITAL STATUS): "M"stands for Married,and "S" stands for Single.
DISCOUNTS:A reduced rate applies for each Discount listed.
s;uno ia u
o�-iz•zon
Os475
0210