HomeMy WebLinkAbout26-001 Robert Mittelstaedt for Presentation on E-Bikes and Youth SafetyCITY OF
mumel SHORT FORM ENTERTAINMENT AGREEMENT
CITY OF CUPERTINO
Parks & Recreation Department
CUPERTINO 10185 N. Stelling Road
Cupertino, CA 95014
408-777-3120
--USE OF THIS FORM IS ONLY VALID FOR AGREEMENTS UP TO $3,500.00 --
Contractor Name: Robert Mittelstaedt
Contractor Authorized Representative: Robert Mittelstaedt
By the signature of its Authorized Representative below, Contractor hereby agrees to the following:
A. SCOPE OF SERVICES. Contractor shall provide or furnish the following specified services
and/or materials: Presentation on E -Bikes and Youth Safety
Location: Community Hall
Time: 6:00 PM - 7:30 PM Plus Set Up and Clean Up
B. TERM. The services and/or materials furnished under this Agreement shall be provided from
5/6/2026 to 5/6/2026.
C. COMPENSATION. For the full performance of this Agreement, the City of Cupertino shall pay
Contractor a total of $500.00 in a lump sum to be paid following receipt of Contractor's invoice.
D. EXHIBITS. The following attached exhibits hereby are made part of this Agreement:
X- Exhibit "C" - Affidavit of No Employees
GENERAL TERMS AND CONDITIONS
1. 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 the Scope of 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 agreement.
2. General Liability Insurance. The undersigned shall maintain general liability insurance in an
amount not less than one million dollars ($1,000,000) per occurrence for bodily injury, personal
injury, and property damage. Undersigned's general liability policies shall be endorsed to
provide that City and its officers, officials, employees, and agents shall be additional insureds
under such policies.
3. Compliance with Laws. Contractor shall comply with all laws applicable to this Agreement
including, without limitation, laws regarding workers' compensation, antidiscrimination, and
conflict of interest. If Contractor has no employees an affidavit to that effect shall be attached to
this agreement. If the scope of work involves providing services to children, the City of
Cupertino, Contractor Declaration shall be attached.
4. Assignment. Contractor may not assign, transfer, or subcontract this Agreement or any portions
thereof, without prior written consent of City.
5. Termination. City may terminate this agreement at any time. In the event of cancellation within
24 hours of the time Contractor is to begin providing services City shall pay contractor one half
of the total agreement amount unless cancellation occurs after Contractor's personnel have
arrived at the location where services are to be performed in which case the total contract
amount shall be paid.
6. Interest of Contractor. It is understood and agreed that this Agreement is not a contract of
employment and, at all times, Contractor shall be deemed to be an independent contractor and
Contractor is not authorized to bind the City to any contracts or other obligations in executing
this Agreement. Contractor certifies that no one who has or will have any financial interest
under this Agreement is an officer or employee of City. City shall have no right of control as to
the manner Contractor performs the services to be performed. Nevertheless, City may, at any
time, observe the manner in which such services are being performed by the contractor.
Contractor shall comply with all applicable Federal, State, and local laws and ordinances
including, but not limited to, unemployment insurance benefits, FICA laws, and the City
business license ordinance.
7. Changes. No changes or variations of any kind are authorized without the written consent of
the City.
CONTRACT COORDINATOR and representative for CITY shall be: Birgit Werner.
IN WITNESS WHEREOF, the parties have executed this Agreement effective the date last signed
below.
CITY OF CUPERTINO
A Municipal Corporation
fz
By
Name Chad Mosley
Title Director of Public Works
Date May 1, 2026
APPROVED AS TO FORM:
Michael K Woo
MICHAEL K. WOO
Senior Assistant City Attorney
ATTEST:
LAUREN SAPUDAR
City Clerk
Date May 1, 2026
CONTRACTOR
By
Name Robert mittelstaedt
Title Expert
Date Apr 30, 2026
Tax I.D. No.: 554500254
May 5, 2020
Exhibit C
Contractor/Consultant Affidavit of No Employees
State of California
County of Santa Clara
City of Cupertino
I, the undersigned, declare as follows:
I am an independent contractor and the owner of Robert Mittelstaedt
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 30 day of April , 2026, at ,California.
California.
Robert mittelstaedt
PRINT NAME
SIGNATURE
Revised 2.06.23
CERTIFICATE NO.:
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
II PRODUCER I PUBLIC ENTITY (ADDITIONAL INSURED) II
Alliant Insurance Services, Inc.
P O Box 744963
Los Angeles, CA 90074-4963
License No: OC 36861
NAMED INSURED (EVENT HOLDER): EVENT INFORMATION:
City of Cupertino TYPE: E -Bike & Youth Safety Community
10300 Torre Ave Meeting
Cupertino, CA 95014 DATE(S): May 6, 2026
LOCATION: Cupertino Community Hall
*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 MKLV7PBC002230
MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2026 EXPIRATION: JANUARY 1, 2027
COMMERCIAL GENERAL LIABILITY
OCCURRENCE FORM
DEDUCTIBLE: NONE
General 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
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,000/$3,000,000
❑ $2,000,000/$2,000,000
Damage To Property (If purchased)
Waiver of Subrogation (If Purchased)
Yes No
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
Robert Mittelsteadt
Gwendolyn Froh
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy
AUTHORIZED REPRESENTATIVE:
DATE ISSUED:
ill
MARKEL
EVANSTON INSURANCE COMPANY
IMPORTANT NOTICE
CALIFORNIA SURPLUS LINES NOTICE (D-2)
1. The insurance policy that you have purchased is being issued by an
insurer that is not licensed by the State of California. These companies
are called "nonadmitted" or "surplus lines" insurers.
2. The insurer is not subject to the financial solvency regulation and
enforcement that apply to California licensed insurers.
3. The insurer does not participate in any of the insurance guarantee
funds created by California law. Therefore, these funds will not pay
your claims or protect your assets if the insurer becomes insolvent
and is unable to make payments as promised.
4. The insurer should be licensed either as a foreign insurer in another
state in the United States or as a non -United States (alien) insurer. You
should ask questions of your insurance agent, broker, or "surplus
line" broker or contact the California Department of Insurance at the
toll -free number 1-800-927-4357 or internet website
www.insurance.ca.gov. Ask whether or not the insurer is licensed as a
foreign or non -United States (alien) insurer and for additional
information about the insurer. You may also visit the NAIC's internet
website at www.naic.org. The NAIC — the National Association of
Insurance Commissioners — is the regulatory support organization
created and governed by the chief insurance regulators in the United
States.
5. Foreign insurers should be licensed by a state in the United States
and you may contact that state's department of insurance to obtain
MPIL 1039 -CA 01 20 Page 1 of 2
more information about that insurer. You can find a link to each state
from this NAIC internet website: https://naic.org/state_web_map.htm.
6. For non -United States (alien) insurers, the insurer should be
licensed by a country outside of the United States and should be on
the NAIC's International Insurers Department (IID) listing of approved
nonadmitted non -United States insurers. Ask your agent, broker, or
"surplus line" broker to obtain more information about that insurer.
7. California maintains a "List of Approved Surplus Line Insurers
(LASLI)." Ask your agent or broker if the insurer is on that list, or view
that list at the internet website of the California Department of
Insurance: www.insurance.ca.gov./01-consumers/120-company/07-
Iasli/lasli.cfm.
8. If you, as the applicant, required that the insurance policy you have
purchased be effective immediately, either because existing coverage
was going to lapse within two business days or because you were
required to have coverage within two business days, and you did not
receive this disclosure form and a request for your signature until after
coverage became effective, you have the right to cancel this policy
within five days of receiving this disclosure. If you cancel coverage,
the premium will be prorated and any broker's fee charged for this
insurance will be returned to you.
MPIL 1039 -CA 01 20 Page 2 of 2
State Farm Mutual Automobile Insurance Company
PO Box 2358
Bloomington IL 61702-2358
StateFarm
AT2 A-2 FA6 A
MITTELSTAEDT, ROBERT A &
Policy Number:
Policy Period: April 4, 2026 to October 4, 2026
Vehicle:
2018 TESLA MODEL 3
Principal Driver:
ROBERT A MITTELSTAEDT
CONVENIENT PAYMENT OPTION: You may use one of
State Farm's alternate payment plans which divides your
present premium into two separate payments.
You may pay one half of the amount due, $438.30 on APR
04 2026.
The remaining half will be due on JUN 03 2026. We'll send
you a reminder notice.
We also have available a plan to let you pay your premium
in monthly installments. For details on this plan and to
Policy Number: 435 8811 -D04 -05A
Prepared February 11, 2026
1004583
AUTO RENEWAL
AMOUNT DUE: $876.61
Payment is due by April 04, 2026
Your State Farm Agent
NIMA RAD INSURANCE AGENCY INC.
Office: 415-925-0388
Address: 435 MAGNOLIA AVE UNIT 1
LARKSPUR, CA 94939-2034
If }vu have a new or different car, have added anyddvers, or have moved,
please contact your agent.
Thank you for choosing State Farm.
determine if you qualify, please contact your State Farm
agent.
Notice of insurance information collection practices -
personal, family, or household insurance transactions:
We may collect customer information from persons other
than the individual or individuals applying for coverage.
Such customer information as well as other personal or
privileged information subsequently collected may, in certain
Please fold and tear here
(continued on next page)
Page number 1 of 5
143562 202 01-15-2018
Power To Pay Online
Your Way statefarm.com/pay
Mobile
Use the
State Farm mobile app
Call
Automated Line: 1-800-440-0998
Your agent: 415-925-0388
Mail
f-' Send us
a check
Visit your
State Farm
agent
Key code: 1682024376
StateFarm
Insured: MITTELSTAEDT, ROBERT A &
Policy Number: 435 8811 -D04 -05A
0209604261
State Farm Insurance Companies
P.O. Box 680001
Amount Due: $876.61 Dallas, TX 75368-0001
Please pay by April 04, 2026 IIIIIIII'lllllll'111111'III'II.Il'IIII'lllll'llllllll"'IIIII"II
Make payment to State Farm
For Office Use Only AUTO REN $876.61 0426
1 -Al A 2FA6-FB14
APP DT 05-14-2026 MUTL VOL
00043830 559609400087661 005200435881111102>
£StateFarm
circumstances, be disclosed to third parties without your
authorization as permitted by law.
You have the right to submit a written request to access,
correct, amend, or delete your personal information and the
right to receive a response within 30 days of submitting your
request. If we deny your request, you have the right to file a
statement with us containing the information you feel is
accurate and fair along with the reasons you disagree with
our denial. Instructions on how to file such request and our
full privacy notice can be found
VEHICLE INFORMATION
www.statefarm.com/customer-care/privacy-security/privacy
or contact your State Farm Agent.
When you provide a check as payment, you authorize us
either to use information from your check to make a
one-time electronic fund transfer from your account or to
process the payment as a check transaction. When we use
information from your check to make an electronic fund
transfer, funds may be withdrawn from your account as soon
as the same day we receive your payment, and you will not
receive your check back from your financial institution.
Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please
let us know right away.
Vehicle Identification
Vehicle Description Number (VIN) Who principally drives this vehicle? How is this vehicle normally used?
Other Household Vehicle(s)
Your premium may be influenced by other State Farm
policies that currently insure the following vehicle(s)
in your household:
2014 BMW X3
2023 VOLVO XC60
Policy Number: 435 8811 -D04 -05A
Prepared February 11, 2026
Page number 2 of 5
Thanks for being part
of our neighborhood.
You mean a lot to us. If you have
any questions or need anything,
please call State Farm® Agent
NIMA RAD INSURANCE
AGENCY INC. at 415-925-0388.
TP3 1
StateFarm
The premium on the expiring policy term was based on
8,000 miles per year.
The premium on the renewal policy term was based on
8,000 miles per year.
Premium Adjustment
Each year, we review our medical payments and personal
injury protection coverages claim experience to determine
the vehicle safety discount that is applied to each make and
DRIVER INFORMATION
Assigned Driver(s)
The following driver(s) are assigned to the vehicle(s) on this policy.
model. In addition, we review the comprehensive, collision,
bodily injury and property damage claim experience
annually to determine which makes and models have
earned decreases or increases from State Farm's standard
rates. If any changes result from our reviews, adjustments
are reflected in the rates shown on this renewal notice.
Driving Experience as of Marital
Name April 04, 2026 Status
ROBERT A MITTELSTAEDT 62 years Married
Other Household Driver(s)
In addition to the Principal Driver(s) and Assigned
Driver(s), your premium may be influenced by the
drivers shown below and other individuals permitted to
drive your vehicle. This list does not extend or expand
coverage beyond that contained in this automobile
policy. The drivers listed below are the drivers reported
to us that most frequently drive other vehicles in your
household.
ANITA W HANSEN
It is your responsibility to inform us of all regular
drivers of your vehicles and changes to those drivers
throughout the life of your policy. Failure to disclose
drivers may result in denial of coverage. Regular
drivers, regardless of their relationship to the primary
named insured or their residence address, include:
oc All drivers who drive the vehicle(s) on the policy
once or more in a typical month
oc All drivers who regularly drive the vehicle(s) at
least three months of the year
oc For business related vehicles, also include the
business owner(s) and employee(s) that drive the
vehicle(s) in any capacity
Principal Driver & Assigned Drivers
For each automobile, the Principal Driver is the individual
who most frequently drives it.
Each driver is designated as an Assigned Driver on the
household automobile that they most frequently drive. Your
premium may be influenced by the information shown for
these drivers.
COVERAGE AND LIMITS See your policy for an explanation of these coverages.
A
Liability
Bodily Injury 500,000/500,000
Property Damage 100,000 $282.56
C Medical Payments 5,000 $10.83
(continued on next page)
Policy Number: 435 8811 -D04 -05A Page number 3 of 5
Prepared February 11, 2026
StateFarm
COVERAGE AND LIMITS continued
D
100 Deductible Comprehensive
$132.14
G
500 Deductible Collision
$366.52
H
Emergency Road Service
$5.91
U
Uninsured Motor Vehicle
Bodily Injury 250,000/500,000
$75.58
U1
Uninsured Motor Vehicle
Property Damage
$3.07
Amount Due
$876.61
If any coverage you carry is changed to give broader
protection with no additional premium charge, we will give
DISCOUNTS These adjustments have already been applied to your premium.
you the broader protection without issuing a new policy,
starting on the date we adopt the broader protection.
Multiple Line ✓
Multicar ✓
Vehicle Safety
✓
Driving Safety Record
✓
California Good Driver
✓
Loyalty
✓
Total Discounts
$3,801.41
Other Available Discount(s)
You may be eligible for additional discounts
See the enclosed insert for more information.
Mature Driver
SURCHARGES AND DISCOUNTS
Driving Safety Record Rating Plan
Your driving safety record, along with other rating factors,
determines what you pay for Liability, Medical Payments,
Comprehensive, Collision, and Uninsured Motor Vehicle
Coverages. Policyholders with no accidents and convictions
pay less than those with accidents and convictions.
The Driving Safety Record Rate Level that is assigned to
your policy moves up, down, or stays the same every policy
renewal, depending upon your driving record. For every 12
months since the renewal following the occurrence of a
chargeable accident or the conviction of a minor violation,
the initial assigned Driver Record Level for that chargeable
accident or conviction shall be lowered by 1 level. For each
12 month period since the conviction of a major violation,
the initial assigned Driver Record Level for that conviction
shall be lowered by 2 levels. The Rate Level is increased if
there are subsequent chargeable accidents or convictions.
Definition of Chargeable Accidents
Chargeable accidents for new business are those which
resulted in bodily injury or death or in payment(s) by an
insurer due to damage to any property in the amount of
more than $1000. For accidents occurring prior to
December 11, 2011, an accident shall be chargeable
provided it resulted in death or in payment(s) by an insurer
due to damage to any property in the amount of more than
$750.
For applicants without prior insurance at the time of the
accident, an accident shall be chargeable provided it
resulted in damage to any property in the amount of more
(continued on next page)
Policy Number: 435 8811 -D04 -05A
Prepared February 11, 2026
Page number 4 of 5
£StateFarm
than $1000 (more than $750 if the accident occurred prior to
December 11, 2011).
Chargeable accidents for renewal business are those which
resulted in bodily injury or death or State Farm claim
payments totaling more than $1000 (more than $750 for
accidents occurring prior to December 11, 2011) under
ADDITIONAL INFORMATION
IMPORTANT NOTICE
For your protection California law requires the
following to appear with this policy: Any person who
knowingly presents false or fraudulent information to
obtain or amend insurance coverage or to make a claim
for the payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
property damage liability coverage and collision coverage
combined.
For more information about the rating plan, please contact
your State Farm agent.
Superior Driver Rate Level
If any information on this renewal notice is incomplete or
inaccurate, or if you want to confirm the information we have
in our records, please contact your agent. For additional
information regarding discounts or coverages, see your
State Farm agent or visit statefarm.com®.
Endorsement 6130Q effective APR 04 2026.
Important Notice Regarding Your Premium
State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile
insurance is determined by many factors including:
oc The coverage you have
cc Where you live
cc The kind of car you drive
oc How the car is used
cc Who drives the car
Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent.
Buying a new car? Remember to contact your agent!
When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent
promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as
the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help:
cc avoid any complications or lack of coverage in the event of an accident or loss,
cc avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and
cc ensure that you receive any new discounts you may be entitled to.
Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited
number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state.
If you have any questions about coverage for a newly acquired car, please contact your State Farm agent.
Disclaimer: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and
conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any
applicable endorsements.
Policy Number: 435 8811 -D04 -05A Page number 5 of 5
Prepared February 11, 2026