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25-158 Jeff Clark Sound Equipment and Engineer for Fall Bike Fest 2025 SHORT FORM ENTERTAINMENT AGREEMENT CITY OF CUPERTINO Parks & Recreation Department 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: Jeff Clark Contractor Authorized Representative: Jeff Clark 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: Provide amplified sound system for Fall Bike Fest - sound tower and fill speaker as necessary Location: Civic Center Plaza Time: 9:00 AM - 1:00 PM (Set up starts at 7:30AM) B. TERM. The services and/or materials furnished under this Agreement shall be provided from 9/27/2025 to 9/27/2025. C. COMPENSATION. For the full performance of this Agreement, the City of Cupertino shall pay Contractor a total of $450.00 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: - Exhibit "C" - Affidavit of No Employees - Exhibit "D" - Contractor's Mandated Reporter Declaration if Contractor provides services to children 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. May 5, 2020 IN WITNESS WHEREOF, the parties have executed this Agreement effective the date last signed below. CITY OF CUPERTINO A Municipal Corporation By Name Title Date CONTRACTOR By Name Title Date Tax I.D. No.: APPROVED AS TO FORM: MICHAEL K. WOO Senior Assistant City Attorney ATTEST: KIRSTEN SQUARCIA City Clerk Date Jeff Clark Sound Engineer Sept 11, 2025 559-49-6757 Chad Mosley Director of Public Works Sept 17, 2025 Sept 17, 2025 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 Jeff Clark. 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 ____day of ____________, 2025, at , California. ______________________________ PRINT NAME ______________________________ SIGNATURE 11 September Santa Cruz Jeff Clark CERTIFICATE NO.: - CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. P O Box 744963 Los Angeles, CA 90074-4963 License No: OC 36861 City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants NAMED INSURED (EVENT HOLDER): City of Cupertino 10300 Torre Ave Cupertino, CA 95014 EVENT INFORMATION: TYPE: 2025 Cupertino Fall Bike Fest DATE(S): September 27, 2025 LOCATION: Cupertino Civic Center, 10350 Torre Ave, Cupertino, CA 95014 *Liquor Liability Yes No **Liquor Liability after 12 am ends before 2 am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER MKLV7PBC001969 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2025 EXPIRATION: JANUARY 1, 2026 COMMERCIAL GENERAL LIABILITY General Aggregate Limit Products & Completed Operations Personal & Advertising Injury Each Occurrence Limit Damage To Premises Rented To You (Any One Premises) Medical Payments (Any One Person) Liquor Liability (If purchased) 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) X Yes No $ 2,000,000 1,000,000 1,000,000 1,000,000 100,000 5,000 1,000,000 OCCURRENCE FORM DEDUCTIBLE: NONE SPECIAL CONDITIONS: The following endorsements attached to the Master Policy do not apply to this Certificate Of Insurance: 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 Bicycle Solutions Black Mountain Composite Mountain Bike Team Civic Park Master Association CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: 7/7/25 MPIL 1039-CA 01 20 Page 1 of 2 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 2 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- lasli/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. © Insurance Services Office, Inc., 2012 Page 1 of 1 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 A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1.In the performance of your ongoing operations; or 2.In connection with your premises owned by or rented to you. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 POLICY NUMBER: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Name Of Additional Insured Person(s) Or Organization(s): City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, and Volunteers Page 1 of 2MDIL 1001 08 11 EVANSTON INSURANCE COMPANY FORMS SCHEDULE POLICY NUMBER: MKLV7PBC001969 FORM NUMBER FORM NAME MJIL 1000 08 10 MPIL 1007 01 20 MPIL 1039-CA 01 20 MPIL 1041 02 20 MPIL 1083 04 15 MDIL 1001 08 11 IL 00 21 09 08 MEIL 1231 10 13 MDGL 1008 08 11 BC CG 00 01 04 13 CG 02 24 10 93 CG 20 01 04 13 CG 20 11 04 13 CG 20 26 04 13 CG 21 33 11 85 CG 21 47 12 07 CG 21 58 04 13 CG 21 70 01 15 CG 21 76 01 15 CG 21 96 03 05 IL 00 17 11 98 MEGL 0241 05 16 MEGL 1639 08 14 MEGL 2300 11 19 MEGL 2322 05 21 MEGL 5300 05 16 MEGL 5302 05 16 MEGL 5303 05 16 MEIL 1200-CA 02 23 MEIL 1225 10 11 MEIL 1251 10 21 MGL 1319 01 16 MGL 1356 10 20 MIL 1214 09 17 IL 12 01 11 85 MDIL 1000-CA 08 11 Common Policy Declarations Policy Changes - for CA Trade or Economic Sanctions Exclusion - Cyber Incident, Data Compromise, And Violation Of Statutes Related To Personal Data Exclusion - Unmanned Aircraft Two Or More Coverage Forms or Policies Changes - Civil Union Service Of Suit - California Exclusion - Lead Exclusion - Asbestos Exclusion-Organic Pathogen And Legionellae Exclusion - Communicable Disease Exclusion - Marijuana Excl - Aircraft and Hot Air Balloon Rides, Demos & Waiver Of Transfer of Rights Against Others to Us Common Policy Conditions ESX Silica Or Silica-Related Dust Exclusion Exclusion Of Punitive Damages Related To A Certified Act Of Terrorism Cap on Losses From Certified Acts of Terrorism Exclusion - Professional Veterinarian Services Employment Related Practices Exclusion Exclusion - Designated Products Additional Insured - Desg Person or Organization Additional Insured-Managers or Lessors of Premises Primary & Noncontributory - Other Ins Condition Earlier Notices of Cancellation Provided By Us Commercial General Liability Coverage Form Commercial General Liability Coverage Part Declarations Minimum Earned Premium And Minimum Retained Premium Nuclear Energy Liability Exclusion Endorsement GD Forms Schedule U.S. Treasury Department's Office Of Foreign Assets Control ("OFAC") Advisory Notice To Policyholders How To Report A Claim California Surplus Lines Notice (D-2) Privacy Notice Policy Jacket/Signature Page Page 2 of 2MDIL 1001 08 11 Abuse, Molestation, Or Exploitation Coverage-Defense Costs Within Limits Concert or Performance Exclusions and Limitations Exclusion - Aircraft and Watercraft Liability Assumed Under An Insured Contract Exclusion - Amusement Devices and Rides Exclusion - Boxing, Wrestling and Contact Martial Arts Exclusion - Entertainers, Participants and Equipment Exclusion - Fireworks, Pyrotechnics and Flashboxes Exclusion - Motorized Sporting Events Exclusion - Professional Sporting Events Exclusion - Rodeos and Roping Events Exclusion - Obstacle Course Races and Mud Runs Additional Insured - Concessionaires, Exhibitors and vendors Aggregate Limit of Insurance Broadened Insurance Damage to Property Coverage Liquor Liability Coverage Premium Reporting Primary and Noncontributing Insurance Exclusion-Abuse, Molestation, Or ExploitationMEGL 2632 01 24 MEGL 1857 11 17 MEGL 1856 10 14 MEGL 1855 08 14 MEGL 1854 08 14 MEGL 1853 10 14 MEGL 1852 08 14 MEGL 1851 08 14 MEGL 1664 08 15 MEGL 1647 08 14 MEGL 1646 08 14 MEGL 1645 08 14 MEGL 1644 08 14 MEGL 1643 08 14 MEGL 1642 10 14 MEGL 1641 05 16 MEGL 1640 08 14 MEGL 1638 11 19 MEGL 0205 01 24 © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 01 04 13 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1)The additional insured is a Named Insured under such other insurance; and (2)You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1IL 00 17 11 98 COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A.Cancellation 1.The first Named Insured shown in the Declarations may cancel this policy by mailing or delivering to us advance written notice of cancellation. 2.We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: a.10 days before the effective date of cancellation if we cancel for nonpayment of premium; or b.30 days before the effective date of cancellation if we cancel for any other reason. 3.We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4.Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5.If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be effective even if we have not made or offered a refund. 6.If notice is mailed, proof of mailing will be sufficient proof of notice. B.Changes This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. C.Examination Of Your Books And Records We may examine and audit your books and records as they relate to this policy at any time during the policy period and up to three years afterward. D.Inspections And Surveys 1.We have the right to: a.Make inspections and surveys at any time; b.Give you reports on the conditions we find; and c.Recommend changes. 2.We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to insurability and the premiums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a.Are safe or healthful; or b.Comply with laws, regulations, codes or standards. 3.Paragraphs 1. and 2. of this condition apply not only to us, but also to any rating, advisory, rate service or similar organization which makes insurance inspections, surveys, reports or recommendations. 4.Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recommendations we may make relative to certification, under state or municipal statutes, ordinances or regulations, of boilers, pressure vessels or elevators. E.Premiums The first Named Insured shown in the Declarations: 1.Is responsible for the payment of all premiums; and 2.Will be the payee for any return premiums we pay. F.Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named insured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. INTERLINE IL 00 17 11 98 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1MEGL 0241 5 16 EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us under Section IV – Commercial General Liability Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule of this endorsement with respect to written contracts that exist between you and such person or organization, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule of this endorsement. All other terms and conditions remain unchanged. SCHEDULE COMMERCIAL GENERAL LIABILITY POLICY NUMBER: MKLV7PBC001969 Name Of Person Or Organization: Additional Premium:$150 per Tenant/User or Instructor/Recreation Event Waiver is provided to a state or municipal public entity when required for an individual "Tenant/User Event" or "Instructor/Recreation Event", and when this waver has been elected and purchased for that individual event. A Tenant/User Event is an event that is held or sponsored by companies, organizations, or individuals that have been permitted to use your premises. An Instructor/Recreation Event is an event that is instructional to its participants. Instructors are not employees of the public entity, but provide instructional services for a fee. Form_SCTNID_CTGRY.CA05216489_DECPAGE 973898350 Q FB86020 INS DECPAGE U POLWHITEFONT A4NUBNA63NP4UTGWBLG2SZDBMH0002 RPUID TRACWHITEFONT BDF_PCA Policy number: Underwritten by: Progressive Express Ins Page of Policy Period: Apr 1, 2025 1 2 - January 27, 2025 Oct 1, 2025 Online Service Make payments, check billing activity, print policy documents, update your policy or check the status of a claim. progressivecommercial.com For customer service and claims service, 24 hours a day, 7 days a week. 1-800-895-2886 Cleveland, OH 44101 P.O. Box 94739 Progressive Named insured Commercial Auto Insurance Coverage Summary This is your Renewal Declarations Page This Renewal Declarations Page is effective only if the minimum amount due to renew your policy is received or postmarked by April 1, 2025. Your coverage begins on April 1, 2025 at 12:01 a.m. This policy expires on October 1, 2025 at 12:01 a.m. Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for an auto may not be combined with the limits for the same coverage on another auto, unless the policy contract allows the stacking of limits. The policy contract is form 6912 (02/19) . The contract is modified by forms 2852CA (03/24), 4852CA (02/19), 4881CA (02/19) and Z228 (01/11). The named insured organization type is a sole proprietorship. Outline of coverage Description Limits Deductible Premium……………………………………………………………………………………………………………………………………………………….. Bodily Injury and Property Damage Liability $750,000 combined single limit Liability To Others $273 ……………………………………………………………………………………………………………………………………………………….. Uninsured/Underinsured Motorist $750,000 combined single limit 73……………………………………………………………………………………………………………………………………………………….. Rejected --Uninsured Motorist Property Damage……………………………………………………………………………………………………………………………………………………….. Rejected --Medical Payments Subtotal policy premium ……………………………………………………………………………………………………………………………………………………….. $346.00……………………………………………………………………………………………………………………………………………………….. California Vehicle Assessment Fee 0.88 ………………………………………………………………………………………………………………………………………………………..Total 6 month policy premium and fees $346.88 Important information about fees The following additional fees may apply: Late payment fee $10.00 Fee for returned checks or refused payments $20.00 Rated drivers ………………………………………………………………………………………………………………………………………………….. Jeffrey Clark1.W 4 Continued Form 6489 CA (05/21) 973898350 Q FB86020 INS DECPAGE U POLWHITEFONT A4NUBNA63NP4UTGWBLG2SZDBMH0002 RPUID TRACWHITEFONT BDF_PCA Policy number: 973898350 Jeffrey W Clark Page of 2 2 Auto coverage schedule 1. Liability Premium ……………………………………………………………………………………………………………………………………………… $346 Auto Total Liability Premium $273 UM/UIM Premium $73 Important Notice For your protection California law requires the following to appear on this form. 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. Company officers President Secretary Form 6489 CA (05/21) Confirmation of Coverage Dear: , IMA, Inc. - Pasadena Date: Jul 14, 2025 Thank you for the bind order for the below Insured. We are pleased to present the RPS Confirmation of Coverage and invoice along with the attached Tysers Insurance Brokers Ltd binder. Please review the attached and below carefully as coverage described herein may be different from the original application submitted, or prior policy if applicable. Insured: City of Cupertino DBA: Department of Recreation and Community Services, Public Works Department RPS Reference #: 7563472A Mailing Address: 10300 Torre Avenue Cupertino, CA 95014 Physical Address: 10300 Torre Avenue, Cupertino, CA 95014 Carrier: Underwriters at Lloyd's, London Carrier Status: Non-Admitted / AM Best Rating: A+ XV Policy Number: MR254153 Expiring Policy Number: MR244153 Policy Period: 7/1/2025 to 7/1/2026 Coverage: Special Casualty - Sexual Misconduct Limit of Liability: a)USD 5,000,000 in the aggregate during the policy period for all claims brought by or on behalf of each victim, and b)USD 5,000,000 in the aggregate during the policy period for all claims brought by or on behalf of all victims and separately: c)USD 75,000 in the aggregate during the policy period for all safeguard costs resulting from all circumstances Retention: USD 35,000 each Victim Policy Premium:$45,000.00 Fees (fully earned): Taxes: Surplus Lines Tax $1,350.00 Stamping Office Fee $81.00 TRIA: Status: TOTAL: $46,431.00 Minimum Earned Premium: Home State: CA The State Surplus Lines Notice applies only if Insurance Carrier is shown as Non-Admitted in the Binder Information Section. Conditions/ Subjectivities: per Carrier terms attached Please see attched company quote for complete limits, terms, conditions, and exclusions. Please note: ·You are responsible for reviewing and explaining the coverage to the client, including any options, available or not from our office. The terms hereon are not fully described and no assumption should be made as to the adequacy of the coverage of the risk to the client. ·You are not an Agent of the insurer, and as such, cannot bind coverage nor make any commitments on behalf of the insurer, nor of us. This policy cannot be assigned to another without the written consent of the insurer or their Agent. ·This document is intended for use as evidence that the insurance, as described herein, has been effected and shall be subject to all terms and conditions of policy(ies) which will be issued and that in the event of any inconsistency herewith, the terms and provisions of such policy(ies) shall prevail. ·If this policy is issued on a non-admitted basis, your office is responsible for completing, collecting and delivery to RPS any required surplus lines forms, taxes and fees from the insured. RPS will remit the applicable taxes and forms to the state. If this policy is subject to the surplus lines laws in your state, you should make every effort to comply with any special provisions and regulations of your state. ·By binding you commit to any provisions contained hereon, such as Minimum Earned Premiums. There are no flat cancellations allowed. ·When requesting a policy change, addition, cancellation, endorsement, etc. you must provide every policy number/ coverage to which the request applies. ·You are responsible for the issuance and review of Certificates of Insurance (COI). COIs cannot amend or alter the terms provided herein. ·In the event of a claim please report immediately and visit the RPS Claims website: https://my.rpsins.com/claimsfnol ·All premiums and any fees are due to RPS within 20 days of binding unless otherwise stipulated. Accounts with payments that are overdue and are not received within this time frame are subject to cancellation. If you have any questions, please feel free to call or email me. We look forward to our next opportunity to work with you. Sincerely, Shawn McCall Risk Placement Services, Inc. - PNP Phone: (630) 285-4079 Email:shawn_mccall@rpsins.com Jeff Clark Sound Equipment and Engineer for Fall Bike Fest 2025 Final Audit Report 2025-09-17 Created:2025-09-04 By:Webmaster Admin (webmaster@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAP4DB3xm4IXRiAUlVKCZT7xIEACMucyuZ "Jeff Clark Sound Equipment and Engineer for Fall Bike Fest 20 25" History Document created by Webmaster Admin (webmaster@cupertino.org) 2025-09-04 - 9:27:45 PM GMT- IP address: 35.229.54.2 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2025-09-04 - 9:53:13 PM GMT Email viewed by Araceli Alejandre (aracelia@cupertino.org) 2025-09-04 - 9:53:20 PM GMT- IP address: 35.168.114.244 Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2025-09-05 - 3:15:09 PM GMT - Time Source: server- IP address: 71.202.76.156 Document emailed to for signature 2025-09-05 - 3:15:11 PM GMT Email viewed by 2025-09-08 - 10:40:32 PM GMT- IP address: 63.249.94.6 Email viewed by 2025-09-12 - 0:26:30 AM GMT- IP address: 63.249.94.6 Signer entered name at signing as Jeff Clark 2025-09-12 - 3:47:32 AM GMT- IP address: 63.249.94.6 Document e-signed by Jeff Clark ( Signature Date: 2025-09-12 - 3:47:34 AM GMT - Time Source: server- IP address: 63.249.94.6 Document emailed to Michael Woo (michaelw@cupertino.org) for signature 2025-09-12 - 3:47:37 AM GMT Email viewed by Michael Woo (michaelw@cupertino.org) 2025-09-12 - 3:47:45 AM GMT- IP address: 98.81.29.74 Email viewed by Michael Woo (michaelw@cupertino.org) 2025-09-17 - 5:29:12 PM GMT- IP address: 18.232.123.41 Document e-signed by Michael Woo (michaelw@cupertino.org) Signature Date: 2025-09-17 - 6:00:08 PM GMT - Time Source: server- IP address: 64.165.34.3 Document emailed to Chad Mosley (chadm@cupertino.org) for signature 2025-09-17 - 6:00:10 PM GMT Email viewed by Chad Mosley (chadm@cupertino.org) 2025-09-17 - 6:00:20 PM GMT- IP address: 44.200.137.229 Document e-signed by Chad Mosley (chadm@cupertino.org) Signature Date: 2025-09-17 - 7:05:44 PM GMT - Time Source: server- IP address: 64.165.34.3 Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature 2025-09-17 - 7:05:46 PM GMT Email viewed by Kirsten Squarcia (kirstens@cupertino.org) 2025-09-17 - 7:05:53 PM GMT- IP address: 3.215.142.15 Document e-signed by Kirsten Squarcia (kirstens@cupertino.org) Signature Date: 2025-09-17 - 7:26:12 PM GMT - Time Source: server- IP address: 64.165.34.3 Agreement completed. 2025-09-17 - 7:26:12 PM GMT