No preview available
18-001 Juan He CITY OF No. ofFS-14-7J 19 FY2018-19 CUPERTINO RECREATION SERVICES AGREEMENT 1. Parties. This contract is made and entered into as of April 3, 2018 ("Effective Date"),by and between the City of Cupertino, a municipal corporation("City"), and Juan He, ("Contractor"), a sole proprietor for dance instruction. 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 Tune 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$12,000 ("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. 3-14-2018 Page 1 of 12 of care to protect City information as a reasonably prudent Contractor would use to protect its own proprietary data. 7. Ownership of Materials.To the extent Contractor prepares written material, drawings or data in connection with this contract, City will have the property rights to those materials and all copyrights,if any, to such work product will constitute City property. / 8. Records. Contractor must maintain complete,accurate,and detailed accounting records relating to its performance in accordance with generally accepted accounting principles and procedures. The records must include detailed information about Contractor's services,benchmarks, deliverables and costs/fees,and must be made reasonably available to City.The records and supporting documents must be kept separate from other files and maintained for four years from the date of City's final payment. 9. Assignment.This Contract is not assignable. Contractor may not substitute another or transfer any rights or obligations under this Contract without prior written approval of City.Only those persons whose names are included in Exhibit A may perform the Services. 10. Publicity and Signs. Any publicity generated by Contractor related to this contract or the Services during the Contract Time and for one year thereafter must reference City contributions. The words "City of Cupertino" shall be displayed in all pieces of publicity, including flyers, press releases, posters, brochures, public service announcements, interviews and newspaper articles. No signs may be posted, exhibited or displayed on or about City property, except signage required by law or under this Agreement without prior written approval from City. 11. Indemnification.To the fullest extent allowed by law and except for losses caused by the sole negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend, and hold harmless the City, its City Council, boards and commissions, officers, officials, employees, agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal counsel acceptable to City, from and against any liability for damages, claims, actions, causes of action, demands, charges, losses, costs and expenses (including attorney fees,legal costs and expenses related to litigation, arbitrations, administrative and regulatory proceedings), of every nature, arising out of or in any way related to Contractor's or Contractor's agents performance of this contract or the Services. This includes but is not limited to Liability resulting in personal injury, death, property damage, or economic losses. Contractor must pay any costs City may incur in enforcing this provision and must accept a tender of defense upon receiving notice from City. Contractor's payments may be deducted or offset to cover any money the City lost due to a claim or counterclaim arising out of this Contract. 12. Insurance. Contractor shall comply with the insurance requirements in Exhibit B. City will not execute the Agreement until it has received and approved satisfactory certificates of insurance and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole discretion may purchase insurance and deduct the costs from payments to Contractor, or terminate the contract. Recreation Services Agreement/Rev. 3-14-2018 Page 2 of 12 13. Compliance with Laws and Other City Requirements. Requirements for all Contracts. This contract is subject to local, state and federal laws and regulations prohibiting discrimination,including Title VII of the Civil Rights Act of 1964,the California Fair Employment Practices Act,the Americans with Disabilities Act of 1990,and other laws that pertain to fair employment and anti-discrimination practices. Contractor must comply with labor laws pertaining to prevailing wages, working hours, overtime, payroll records, and other requirements imposed by the Department of Industrial Relations.If Contractor does not have employees,it must sign the Affidavit of No Employees, attached as Exhibit C. Consultant is responsible for verifying employment eligibility of employees pursuant to the Ixnrnigration 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 goverrunental 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, httl2s:Z/www.cdc.gov/­­l­­`-ieadsul2/index.htmI 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 uz 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 Agreeinent/Rev. 3-14-2018 Page 3 of 12 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: Karen Levy Name:Juan He Position:Recreation Coordinator Position:Dance Instructor Contact:karenl@cupertiulo.org;408-777-3123 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. 3-14-2018 Page 4 of 12 IN WITNESS WHEREOF, the parties have caused this contract to be executed. CONTRACTOR CITY OF CUPERTINO Juan He A Municipal Corporation By By Name n N Hk Name �7SfJJs 77 Title � fi�1Com^ Title/k5:/, C:�`ey— Dater, . ?-8 . >4I i Date 3 , Tax I.D. No.:refer to W-9 on file APPROVED AS TO FORM: ATTEST: RANDOLPH STEVENS6N HOM GRACE SCHMIDT fS Cupertino City Attorney City Clerk ContractlEncumbered Amount: $12,000 Account No.:580-63-620 Recreation Services Agreement/Rev. 3-14-2018 Page 6 of 12 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 Indenmification,Insurance, Ownership of Materials,Records, Governing Law and Attorney Fees,will survive the expiration or termination of this Agreem&ht.' 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: Karen Levy Juan He Email: karenl@cupertuno.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 bundiing obligation of Contractor, and may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. Recreation Services Agreement/Rev. 3-14-2018 Page 5 of 12 EXHIBIT A SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES The CONTRACTOR will provide DANCE INSTRUCTION in,but not Iimited to,the following: CONTEMPORARY& CHINESE DANCE 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 performed pursuant to this Agreement. Compensation shall consist of the following: 65% of resident fees plus 65%of drop-in fees. The total compensation to the Contractor shall not exceed$12,000. (FY 17/18=$1000;FY 18/19=$5500;FY 19/20=$5500). Eligible Participant Minimum and Maximums for CONTRACTOR Services: Minimum: 10 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 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. Recreation Services 4greenient/Rev. 3-14-2018 Page 7 of 12 EXHIBIT B INSURANCE REQUIREMENTS Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the Contractor,his agents,representatives, employees or subcontractors. MINIMUM SCOPE AND LIMIT OF INSURANCE Coverage shall be at least as broad as: 1. Commercial General Liability(CGL):Insurance Services Office Form CG 00 01 covering CGL on an "occurrence"basis,including property damage,bodily injury and personal&advertising injury with limits no less than$2,000,000 per occurrence.If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location(ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Sexual Abuse/Molestation insurance or the equivalent are required for contracts involving children in after school activities,recreational programs,athletics, studies,transportation of students. Covers potential claims of abuse or child molestation. Sexual Abuse/Molestation coverage must be included under General Liability or obtained in separate policies in an amount of not less than$1,000,000 per occurrence ($2,000,000 aggregate) and$3,000,000 excess/umbrella coverage. 3. Automobile Liability:If applicable, a declaration page showing current proof of automobile insurance, displaying coverage amounts at or above the California statutory miniunums,is required. 4.Workers'Compensation insurance as required by the State of California,with Statutory Limits, and Employer's Liability Insurance with limit of no less than$1,000,000 per accident for bodily injury or disease. (Note—required only if Contractor has employees). If the contractor maintains broader coverage and/or higher limits than the minimums shown above, the City requires and shall be entitled to the broader coverage and/or higher limits maintained by the contractor. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. Self-Insured Retentions Self-insured retentions must be declared to and approved by the City.The City may require the Contractor to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention.The policy language shall provide,or be endorsed to provide,that the self- insured retention may be satisfied by either the named insured or City. Other Insurance Provisions The general liability policy is to contain, or be endorsed to contain,the following provisions: Recreation Services Agreeiv.e7it/Rev. 3-14-2018 Page 8 of 12 1. The Entity,its officers,officials,employees, agents,and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Instructor including materials,parts or equipment furnished in connection with such work or operations. 2.For any clairns related to this contract,the Instructor's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 20 0104 13 as respects the Entity,its officers, officials,employees, agents, and volunteers. 3. The Insurance Company agrees to waive all rights of subrogation against the Entity, its elected or appointed officers,officials, agents, and employees for losses paid under the terms of any policy which arise from work performed by the Instructor for the Entity. This provision also applies to the Instructor's Workers' Compensation policy. 4. Each insurance policy required above shall provide that coverage shall not be canceled, except with notice to the Entity. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M.Best's rating of no less than A: VII,unless otherwise acceptable to the Entity. Verification of Coverage Instructor shall furnish the Entity with original certificates and amendatory endorsements effecting coverage required by this clause. All certificates and endorsements are to be received and approved by the Entity before work cointmences. The Entity reserves the right to require complete, certified copies of all required insurance policies, including endorsements affecting the coverage required by these specifications, at any time. We strongly recommend obtaining a copy of the policy declarations and endorsement page (make this a requirement in your Contract)to facilitate verification of coverages and spot any undesirable policy limitations or exclusions. Homeowner's Insurance In some cases the Instructor's homeowner's liability insurance may provide coverage sufficient to meet these requirements.Instructor should provide these requirements to his or her agent to confirm and provide verification to the Entity. Special Events Coverage for Instructors Special events coverage is available for an additional fee to provide the liability insurance required by this agreement.Instructor can obtain additional information and cost from the Entity. Special or Low Risk Activities Entity reserves the right to modify these requirements,including limits,based on the nature of the risk, prior experience,insurer, coverage,or other special circumstances.The Entity reserves the right to modify or waive insurance requirements for certain low risk recreational activities. Recreation Services Agreement/Rev. 3-14-2018 Page 9 of 12 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 dance instructor. 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 L� day of 2018, at Cupertino. California. �11�A N PRINT NAME SIGNATURE Recreation Services Agreement/Rev. 3-14-2018 Page 10 of 12 EXHIBIT D Contractor's Mandated Reporter Declaration The undersigned does hereby certify that: 1. I am a representative of JUAN HE; that I am familiar with the facts herein and am authorized and qualified to execute this declaration. 2. 1 declare that JUAN HE 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. 1 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"): self 8. 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. Recreation Services Agreement/Rev. 3-14-2018 Page 11 of 12 I declare under penalty of perjury that the foregoing is true and correct. JUAN HE MMA By: JUAN HE Title: DANCE INSTRUCTOR Date: t1k Y�( Recreation Services Agreement/Rev. 3-14-2018 Page 12 of 12 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 6365-70516566511448 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED) Alliant Insurance Services,Inc.in conjunction with City of Cupertino Apex Insurance Services P.O.Box 6450 Newport Beach,CA 92658 License No:OC 36861 NAMED INSURED(EVENT HOLDER): EVENT INFORMATION: Juan He TYPE: Dance(Various) LOCATION: Quinlan Community Center,10185 North Stelling Road,Cupertino,CA 95014 *Liquor Liability Yes C) No **Liquor Liability after 12 am ends before 2 ant ❑ This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless amended as described in Special Conditions. INSURANCE CARRIER:Evanston Insurance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES: EFFECTIVE: January 01,2018 EXPIRATION: January 01,2019 COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE Aggregate Limit $2,000,000 Products&Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal&Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You.(Any One Premises) 100,000 Certificate Of Insurance: Medical Payments(Any One Person) 5,000 MEGL1643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased 0 $1,000,000/$3,000,000 ❑I■ $2,000,00052,000,000 Property Damage(If purchased) No Property Damage Coverage The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. ��..rr�-tom AUTHORIZED REPRESENTATIVE: F DATE ISSUED: 03/19/2018 POLICY NUMBER: SEP41026 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees,Agents, Servants,Volunteers and Consultants For Certificate No.: 636570516566511448 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage or personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting on your behalf: amount of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law;and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 ©insurance Services Office, Inc., 2012 Page 1 of 1 Auto Auto Insurance Declaration Page INSURANCE Policy Number: 17607-74-36 PremiumsI Fees Effective: 10/25/2017 12:01 AM . . . . .. . . . .. ... . .. . .. . .. . . . . . . ... . . . .. . . .. . . . .. . . . . . . .Expiration: 4/25/2018 12:01 AM Policy Premium $364.50 Named Insured(s):Juan He Fees(*also see Information on Additional $0.88 Address(es): This is not a bill. Underwritten By: Farmers Insurance Exchange 6301 Owensmouth Ave. Your bill with the amount due will be mailed separately. Woodland Hills,CA 91367 Household Drivers Name Driver Status Vehicle Information Veh.# Year/Make/ModeVVIN Coverage Deductible Limit Collision: $1,000 Additional Equipment: $1,000 Coverage Information Limits _--- ... Premiums by Vehicle _._ erage (applicable to oil vehicles) Vehicle 1 Bodily Injury Liability $15,000 each person -- - $214.20 $30,000 each accident Property Liability - - p Y ama e 9 Y each accident Included Permissive User Limit of Full(See Permissive User Included Liability** Limitof Liability in your policy) Medical Coverage Not Covered ............................................. Uninsured Motorist Bodily ...................- ...... Injury Not Covered Co m pre h ensive --- -._. .. ---.. _...... Not Covered Collision $150.30 Additional Equipment Included farmers.com Policy No. 17607-74-36 Questions? Manage your account: Call your agent Lydia L Chang at(626) Go to www.farmers.com to access 560-8267 or email your account any time! Ili@farmersagent.com 56-6176 istEdition 7-16 8/30/2017 Page 1 of 3 Declaration Page(continued) Premiums by Vehicle Limits ._..._._.__ Vehicle 1 Coverage (applicable to.all vehicles) - - - _........_ _.._ - Not Covered Uninsured Motorist Property Damage With Collision ---- --- -- - _... -------------- --- -- --- Not Covered Towing and Road Service Total Premium Per Vehicle $364.50 00- $364.50 Policy Premium Fee Detail Vehicle 1 Total $0.88 $0.88 Anti Fraud Fee "" Fees $0 88 $365.38 001, Policy Premium and Fees Discounts Discount Type Applies to Vehicle(s) Discount Type Applies to Vehicle(s) Anti Lock Brakes 1 Good Driver ........................ ...... Group Farmers Agt 1 Safe Driver Persistency 1 Rating Information Vehicle 1 Details _............................................................................................................................._............................................................................................................................. _................................................ 95014 Garaging Zip .._. _ _...._......_.__ ... ............. 5,000 Current Annual Mileage 5,000 Previous Annual Mileage ..-.. - ..- --.. _.. ... Other Use Vehicle Usage --- - - - -- Years of Driving Experience Policy and Endorsements This section lists the policy form number and any applicable endorsements that make up your insurance contract.Any endorsements that you have purchased to extend coverage on your policy are also listed in the coverages section of this declarations document: 56-56841 st ed.;J70341 st ed.;25-8531 10-12;CA125 1 st ed. Other Information • "YOUR POLICY INCLUDES THE FULL PERMISSIVE USER LIMIT OF LIABILITY.PLEASE SEE PERMISSIVE USER LIMIT OF LIABILITY IN YOUR POLICY FOR FURTHER INFORMATION. • You maybe eligible for a different rate but with different coverage from Farmers Specialty Insurance Company.Please contact your Farmers®agent to discuss your options. farmers.com Policy No. 17607-74-36 Questions? Manage your account: Call your agent Lydia L Chang at(626) Go to www.farmers.com to access 560-8267 or email your account any time! Ili@farmersagent.com 56-6176 1st Edition 7-16 Page 2 of 3 Declaration Page(continued) • The Attorney-In-Fact(AI F)or management fee for your renewed policy will never exceed 20%of the policy's premiums and will be paid out of the premiums.You may wish to consider this information in deciding whether to acceptor decline this offer to renew your policy. • You have the right to designate an additional third party to receive any notice of cancellation for nonpayment of your premium for this policy. Please contact your Farmers®agent if you would like to add,change,or remove a designee. • Farmers Friendly Reviews area great way to make sure you are receiving all the discounts for which you qualify,and identify any potential gaps in coverage.Contact your agent to learn more about the policy discounts,coverage options,and other product offerings that may be available to you. *Information on Additional Fees The"Fees"stated in the"Premium/Fees"section on the front apply on a per-policy,not an account basis.The following additional fees also apply: 1. Service Charge per installment(In consideration of our 2. Late Fee:$10.00(applied per account) agreement to allow you to pay in installments): 3. Returned Payment Charge:$25.00(applied per check, For Recurring Electronic Funds Transfer(EFT) and fully electronic transaction,or other remittance which is not enrolled online billing(paperless): $0.00(applied per honored byyourfinancial institution forany reason including account) but not limited to insufficient funds or a closed account) For other Recurring EFT plans:$2.00(applied per account) 4. Reinstatement Fee: Good (applied per vehicle,20% For all other payment plans:$5.00(applied per account) discount will apply for Good Drivers) If this account is for more than one policy,changes in these fees are not effective until the revised fee information is provided for each One or more of the fees or charges described above maybe policy. deemed a part of premium under applicable state law. Countersignature Authorized Representative farmers.com Policy No. 17607-74-36 Questions? Manage your account: Call your agent Lydia L Chang at(626) Go to www.farmers.com to access 560-8267 or email your account any time! Ili@farmersagent.com 56-6176 1st Edition 7-16 Page 3 of 3