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19-001 Integem, Inc., for Augmented Reality Youth CampsCITY OF fl No. ____ _ FY2018-20 C UPE RTINO RECREATION SERVICES AGREEMENT 1. Parties. This contract is made and entered into as of 6/10/2019 ("Effective Date"), by and between the City of Cupertino, a municipal corporation ("City"), and with INTEGEM INC., 20380 TOWN CENTER LANE, SUITE 295, CUPERTINO, CA 95014 ("Contractor"), a CALIFORNIA CORPORATION for YOUTH CAMPS. 2. Services. Contractor agrees to provide the Services included in the Scope of Work and in accordance with the Schedule of Performance attached in Exhibit A. 3. Term. This contract begins on the Effective Date and ends on 6/30/2020 ("Contract Time"), unless extended or terminated as provided herein. Time is of the essence and Contractor must have sufficient time, resources, and qualified staff to deliver the Services as required. Contractor must promptly notify City of any actual or potential delays to afford the Parties adequate opportunity to address or mitigate such delays. 4. Compensation. City will pay Contractor for satisfactory performance of the Services an amount that will based upon actual costs but that will be capped so as not to exceed $30,000; $8,000 FOR FY18-19, $22,000 FOR FY19-20 ("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, parh1er, 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. R ecreation S ervic es Agreem ent/ R ev. 3-27-2018 Page I of6 6. Proprietary/Confidential Information. To the extent Conh·actor may have access to private or confidential information owned or controlled by the City, Contractor agrees to treat it confidential and use it solely to perform this Agreement. Contractor must exercise the same standard of care to protect City 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 accow1ting 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 w1der 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 annow1cements, 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 cow1sel 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, ad:rrunistrative 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, arnow1t, 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/ R ev. 3-27-2018 Page2of6 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 tl,e 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 fadustrial Relations. If Contractor does not have employees, it must sign the Affidavit of No Employees, attached as Exhibit C. Contractor is responsible for verifying employment eligibility of employees pursuant to the Immigration Reform and Control Act of 1986. Contractor must comply with conflict of interest laws and regulations applicable to this Agreement and avoid conflicts of interest. Conh·actor may be required to file a conflict of interest form for engaging in governmental decisions or serving in a staff capacity, and is hereby advised to review the requirements of California Political Reform Act and the California Code of Regulations. Services may only be performed by persons who are not employed by City and who do not have a contractual relationship with City other than this contract. Contractor agrees to abide by City policies and administrative rules prohibiting gifts to City officials and employees. Additional Requirements for Services Provided to Minors: Contractor and its employees who provide services under this Agreement must comply with these additional requirements: A. Undergo fingerprinting and a criminal background check and verify all employees providing services under this contract have met this requirement. B. Complete a Tuberculosis screening test as required by law and as set forth in Exhibit D. C. Comply with the Mandatory Reporting w,der California Penal Code 11164-1117 4 .3 and with the protocols, reporting, and training required under California Health and Safety Code Section 124235, AB2007, and other laws pertaining to concussion evaluation, removal from play, and return to play protocols. (Refer to Center for Disease Control & Prevention, https://www.cdc.gov/headsup/index.html). D. Submit required forms and acknowledgments included in Exhibit D, and ensure its each participant is provided with a concussion information sheet, signs and returns the forms to the City as required by Health and Safety Code Section 124235. Require coaches and administrators to successfully complete the concussion and head injury education at least once either online or in person, before supervising a participant. Contractor shall offer training, educational materials, or both to each Contractor administrator on a yearly basis . (Training resources are available at the Center for Disease Control & Prevention (link cited above). E. If providing instruction, Contractor must acknowledge and comply with all requirements set forth in the Recreation & Comrnwuty Services Instructor Manual. Check one (if applicable): ~ This contract requires services for cluldren. Recreation S ervices Agreement/ Rev. 3-27-2018 Page 3 of6 D This conh·act 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 fo r Recreation Contracts', proof of finger printing and additional requirements w1der Paragraph 13. The contract amendment will also require the approval of the Director of Recreation and Commwuty 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: Name: Marilu Mejia Position: Recreation Coordinator For Contractor: Name: Eliza Du Position: CEO Contact: marilum@cupertino.org; (408) 777-3124 Contact: eliza.du@integem.com; ( 408) 459-0658 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. Tlus Section survives tlus 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, whetl1er 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 R ec reation S erv ices Agreem ent/ R ev. 3-27-2018 Page 4 of6 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 h1demnification, Insurance, Ownership of Materials, Records, Governing Law and Attorney Fees, will survive the expiration or termination of this Agreement. 26. Notices. All notices and instruments pertaining to material provisions of this contract or significant disputes which are required by law or w1der 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: Office of the City Manager 10300 Torre Ave ., Cupertino CA 95014 cc: Representative/Coordinator: Marilu Mejia Email: marilum@cupertino .org To Contractor: 20380 Town Center Lane, Suite 295, Cupertino, CA 95014 cc: Representative/Coordinator: Eliza Du Email: eliza.du@integem.com 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 calnterry out all actions and services required. This contract constitutes a legally binding obligation of Contractor, and may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constih1te a single binding instrument. R ecreation Services Agreem ent/ R ev. 3-27-2018 Page 5 of6 IN WITNESS WHEREOF, the parties have caused this contract to be executed . CONTRACTOR I:ntegem h1c. By~ Na1~ Title CfQ Date l l /0£/4 { 8= Ta x I.D . No.: lf 3--Lf S-20 3 t I APPROVED AS TO FORM: ~~.~ Reere v. FIEltltt) \-t~C-\. tv-. ~r M . IV'\~ M\ e. r Cupertino ~g City Attorney Contract/Encumbered Amount: $30,000.00 Account No .: 580-62-613-700-702 CITY OF CUPERTINO A Municipal Corporation Bye,;~£ Namef!thn;s/zov ~c,/ Title ,1:£,f · 7J/rr c/UC Date ')_-S"/', ATTEST: GRACE SCHMIDT ·3 -(( '7 7· City Clerk R ecrea tion Services Agreement/ Rev. 3-27-2018 Page 6 of 6 EXHIBIT A SCOPE OF WORK, PERFORMANCE AND PAYMENT SCHEDULES The CONTRACTOR will provide YOUTH CAMPS in, but not limited to, the following: AUGMENTED REALITY CAMPS Location and Time of CONTRACTOR Services: Refer to the Recreation Schedule dated SUMMER 2019 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 fee per participant, based on final roster. The total compensation to the Contractor shall not exceed $30,000 FOR FY18-20. Eligible Participant Minimum and Maximums for CONTRACTOR Services: Minimum: 5 Maximum: 30 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"): Eliza Du Sean Lin 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 ill 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 volw1teers need to complete the City's Waiver of Liability form prior to taking part in the program. If applicable, contractors who are responsible for supervisil1g mil1ors must remail1 with the class w1til a parent of legal guardian has arrived and all minors are released to them. In the event of an illjury occurring to a participant, the Contractor will notify the City withm 1 hour and complete an Incident Report ill the form approved by the City. The Incident Report must be submitted to the City withil1 24 hours of the injury occurril1g. Exhibit B Insurance Requirements for Recreation Contracts As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance for the duration of the contract against claims arising from or in connection with Contractor, its agents , representatives , employees or subcontractors Services under this Agreement. Minimum Scope and Limit of Insurance. Coverage shall be at least as broad as: l. Commercial General Liability (CGL): Insurance Services Office Fom1 CG 00 01 covering CGL on an "occurrence" basis , including property damage, bodily injury and personal & adve1iising injury with limits no less than $1 ,000,000 per occurrence . If a general aggregate limit applies, it must apply separately to this project/location (CG 25 03 or 25 04) or be twice the required occurrence limit. 2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos, Code 8 (hired) and 9 (non-owned), with limits no less than $1,000,000 per accident for bodily injury and property damage. 8 Required if automobile is used to p erform work unde r this contract. D Otherwise, proof of Contractor's p ersonal auto insurance with limits re quired by state law suffices. Contractor shall not transport or us e its p ersonal vehicle to transport participants or perform work under this contract. 3. Workers' Compensation: As required by the State of California, with Statutory and Employer's Liability Insurance limits of no less than $1,000 ,000 per accident for bodily injury or disease. El Required if Contractor has employees . D If no employees, Contractor must sign Affidav it of No Employees . 4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/services involving minors , (i.e ., after school activities, recreational programs , athletics , study/training events and transportation of minors). Coverage may be included under General Liability or be obtained in a separate policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply separately to this contract or be twice the required occurrence limit. ~ Require d if Contra ct in volves services to children. Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance. Self-Insured Retentions: Self-insured retentions must be approved by City. City may require Contractor to provide proof of ability to pay losses and related investigations , claim administration, and defense expenses within the retention . The policy language must provide, or be endorsed to provide, that the self- insured retention may be satisfied by either the named insured or City. Acceptability of Insurers: Insurance must be issued by insurers acceptable to City and licensed to do business in the State of California, with an A .M . Best's financial strength rating of "A" or better and a financial size rating of "VII" or better. OTHER INSURANCE PROVISIONS: The CGL policy must contain, or be endorsed to contain, the following provisions: 1. The City, its City Council, boards and conunissions, officers, officials , employees, agents, servants and volunteers are to be covered as additional insureds with respect to liability arising out of work or Ex h. B Insuranc e for Rec reation Contracts Updat ed 3-26-18 I operations performed by or on behalf of the Contractor including materials , parts or equipment furnished in connection with such work or operations. 2. Contractor's insurance shall be primary insurance coverage at least as broad as ISO CG 20 01 04 13 as respects the City, its officers, officials, employees, agents, and volunteers . 3. The Insurance Company agrees to waive all rights of subrogation against the City , its elected or appointed officers, officials , agents, and employees for losses paid under the terms of any policy which arise from work perfonned by Contractor for City. This provision also applies to the Contractor's Workers' Compensation policy . 4 . Each insurance policy required by this contract shall provide that coverage shall not be canceled, except with notice to the City. Primary Coverage: The Additional Insured coverage under Contractor 's policy shall be primary non- contributory and at least as broad as ISO CG 20 01 04 13 as respects the City and all the insureds/indemnitees . If the limits of insurance required are satisfied in part by Umbrella/Excess Insurance, the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a "primary and non-contributory" basis for the benefit of the Additional Insureds before City 's own insurance is triggered. Notice of Cancellation: Each insurance policy shall provide that coverage shall not be canceled or allowed to expire without written notice to City 30 days in advance or 10 days in advance if due to non-payment of premiums. Such notice must be sent to City via email or certified mail to the attention of the City Manager. Waiver of Subrogation: Contractor grants City a waiver of any right to subrogation which any insurer of said Contractor may acquire against City by virtue of payment of any loss under such insurance. Contractor will obtain any endorsement that may be necessary to effect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. Verification of Coverage: Contractor shall furnish the City with original certificates and amendatory endorsements effecting coverage required by this clause . All certificates and endorsements are to be received and approved by the City before work commences. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements affecting the coverage required by these specifications, at any time. At a minimum Contractor must provide acceptable copies of the policy declarations and endorsement page verifying the required insurance coverages . Homeowner's Insurance: Contractor's homeowner's liability insurance may provide coverage sufficient to meet these requirements. Contractor should provide these requirements to his or her agent to confirm and provide verification to City . Special Events Coverage: Insurers may provide special events coverage for a reduced fee , or City may be able to offer this coverage. Contractor should contact the City Manager's Office for information or assistance . Special Risks or Circumstances: City reserves the right to modify these requirements based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. Exh. B Insurance for R ec reation Contracts Updated 3-26-18 2 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD /YYYY) ~ 10/19/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND , EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S}, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the ~olicy(ies) must have ADDITIONAL INSURED provisions or be endorsed . If SUBROGATION IS WAIVED, subject to the terms and conditions oft e policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandisina K&K Insurance Group , Inc. PHONE 1-800-426-2889 FAX 1-260-459-5105 (A/C, No, Ext): (A/C , Nol: 1712 Magnavox Way E-MAIL info@sportsinsurance-kk.com Fort Wayne IN 46804 ADDRESS : PRODUCER CUSTOMER ID : INSURER($) AFFORDING COVERAGE NAIC# INSURED 2001058035 CP# 469 INSURER A: Nationwide Mutual Insurance Company 23787 lntegem Inc . INSURER B: 20380 Town Center Lane Suite 295 INSURER C: Cupertino, CA 95014 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000390149 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED . NOTWITHSTANDING ANY REQUIREMENT , TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006430600 04/17/19 04/17/20 EACH OCCURRENCE $2,000,000 - =:JcLAIMS-MADE0 OCCUR 12:01 AM EDT 12 :0 1 AM DAMAGE TO RENTED PREMISES (Ea Occurrence\ $1,000,000 MED EXP (Any one person) $5,000 - PERSONAL & ADV INJURY $2 ,000 ,000 - GEN 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 j POLICY D PROJECT D LOC PRODUCTS-COMP/O P AGG $2,000 ,000 OTHER: PROFESSIONAL LIABILITY $2 ,000 ,000 LEGAL LI AB TO PARTICIPANTS $2,000,000 A AUTOMOBILE LIABILITY 6BRPG0000006430600 04/17/19 04/17/20 COMBINED SINGLE LIMIT (Ea $2 ,000,000 accident) -12:01 AM EDT 12:01 AM ANY AUTO BODILY INJURY (Per person) -OWNED ~ SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accidenl) -HIRED NON -OWNED PROPERTY DAMAGE X AUTOS ONLY AUTOS ONLY (Per accident) ,._ X Not provided while in Hawaii ~~:RELLA tj OCCUR EACH OCCURRENCE ,._ EXCESS LIAB CLAIMS-MADE AGGREGATE OED n RETENTION WORKERS COMPENSATION N/A _j PER STATUTEL_j OTHER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y IN E.L . EACH ACCIDENT EXECUTIVE OFFICER/MEMBER D EXCLUDED? (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE II yes , describe under DESCRIPTION OF OPERATIONS below E.L . DISEASE -POLICY LIMIT A MEDICAL PAYMENTS FOR PARTICIPANTS 04/17/19 04/17/20 PRIMARY MEDICAL 6BRPG0000006430600 12:01 AM EDT 12:01 AM EXCESS MEDICAL $250 ,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Medical Expense Reimbursement for Participants (illness) included -$1,000 per participant/claim. Legal Liability to Participants (LLP) limit is a per occurrence limit. ''Note: Coverage is only provided for the camp dates that have been paid for and reported. Please contact our office if you need additional camp dates added to your policy ." Sexual Abuse or Sexual Molestation Liability -$1,000,000 Each Occurrence (included above)/ $1 ,000,000 Aggregate (included above) Camp Type : Computer Camp Date(s): See Attached Additional Remarks Schedule Camp Location : 20380 Town Center Lane, Cupertino , CA, 95014 The City of Cupertino , its City Council, boards and commissions, officers, officials, employees , agents, servants and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. See Attached Additional Remarks Schedule "' This certificate voids and replaces certificate# W01329257 '" CERTIFICATE HOLDER CANCELLATION City of Cupertino SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 10185 N . Stelling Road EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH Cupertino, CA 95014 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE ~~ © 1988-2015 ACORD CORPORATION. All rights reserved . Coverage is only extended to U.S. events and activities. "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Te xas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENC Y CUSTOMER ID: 2001058035 LOG# ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED K&K Insurance Group , Inc . lntegem Inc . 17 12 Magnavo x Way 20380 Town Center Lane Suite 295 Fort Wavne IN 46804 Cupertino , CA 95014 POLICY NUMBER 6BRPG00000064 30600 CARRIER I NAICCODE EFFECTIVE DATE : Nationwide Mutual Insurance Comoanv 23787 04/17/19 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER : ACORD 25 FORM TITLE : Certificate of Liabilit Insurance Camp Date(s): Camp #1 : 6/3/19 to 6/7/19 Camp #2: 6/10/19 to 6/14/19 Camp #3: 6/17/19 to 6/21 /19 Camp #4: 6/24/19 to 6/28 /19 Camp #5 : 7/1/19 to 7/5/19 Camp #6 : 7/8/19 to 7/12/19 Camp #7 : 7/15/19 to 7/19/19 Camp #8 : 7/22/19 to 7/26/19 Camp #9 : 7/29/19 to 8/2/19 Camp #10 : 8/5/19 to 8/9/19 Camp #11 : 8/12/19 to 8/16 /19 Camp Schedule for lntegem , Inc . Page 2 of 2 CP# 469 ACORD 101 (2008/01) ©2008 ACORD CORPORATION . All rights reserved The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006430600 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 Oraanization(s) City of Cupertino 10185 N. Stelling Road Cupertino, CA 95014 The City of Cupertino, its City Council, boards and commissions, officers, officials , employees, agents, servants and volunteers Ref: lntegem Inc. Ref: CP# 469 Information required to complete this Schedule , if not shown above, will be shown in the Declarations . A. Section II -Who Is An Insured is amended to include as an 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 Ill -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. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 6BRPG0000006430600 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARE FULL V. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following : COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: The City of Cupertino , its City Council, boards and commissions, officers, officials, employees, agents, servants and volunteers 10185 North Sterling Cupertino , CA 95014 Insured: lntegem Inc. Effective Dates: 04 /17/2019 / 04/17/2020 Cert# 469 Information required to complete this Schedule, if not shown above, will be shown in the Declarations . The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV -Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above . CG 24 04 05 09 © Insurance Services Office , Inc., 2008 Page 1 of 1 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 1/7/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED , the policy(ies) must be endorsed. If SUBROGATION IS WAIVED , subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confe r rights to the certificate holder in lieu of such endorsement(s). PRODUCER vV" ,Mv CSR HOUSE NAME: Senigaglia Insurance PHONE I FAX ·'" Nn Ext\· IAIC. Nol : 950 S Bascom Ave #2113 E-MAIL ADDRESS : INSURERISl AFFORDING COVERAGE NAIC # San Jose CA 95128 INSURER A : Farmers Insurance Exchange INSURED INSURER B: Mid-Century Insurance Company Integem, Inc . INSURER C: 20380 Town Center Lane INSURER D: INSURER E: Cupertino CA 95014 INSURER F : COVERAGES CERTIFICATE NUMBER: 2019-20 REVISION NUMBER: THIS IS TO C ERTIFY TH AT THE POLICIES OF INSURANCE LISTED BELOW HAV E BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED . NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI TH RESPECT TO WH ICH THI S CERTIFICATE MAY BE ISSU ED OR MAY PERTAIN, THE INSURANCE A FF ORDED BY THE POLICIES DESCRIBED HEREIN IS S UBJECT TO ALL THE TERMS, EXC LU S IONS AN D CONDITIONS OF SUCH POLICIES . LIMITS SHOWN MAY HAV E BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURAN CE •••on un,n POLICY NUMBER IMM/DDNYYYl IMM /DDNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURR EN CE $ 2,000,000 -D CLAIMS -MADE Q OCCUR DAMAGE TO RENTED A PRE MISES !Ea occ urren ce! $· 50,000 X 606314321 1/1/2019 1 /1/2020 MED EXP (Any one person) $ 5,000 -PERSONAL & ADV INJURY $ 2,000,000 -GEN'L AGGREGATE LIMIT APP LIE S PER : GENERA L AGGR EGAT E $ 4,000,000 Fl D PRO-DLOC PRODUCTS -COMP/OP AGG Excluded POLICY JECT $ OTHER : $ AUTOMOBILE LIABILITY COMB INED SIN GLE LIMIT $ !Ea accident! -ANY AUTO BOOILY INJU RY (Per person) $ -ALL OWN ED -SCHEDULED AUTOS AUTOS BOOILY IN JURY (Pe r accident) $ --NON -OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ -- $ UMBRELLA LIAB H OCCUR EACH OCCURRENC E $ - EXC ESS LIAB CLA IMS-MADE AGGREGATE $ DED I I RE TENTI ON $ $ WORKERS COMPENSATION x I m TUTE I I OTH- AND EMPLOYERS' LIABILITY ER YIN ANY PROPRIETOR/PARTNER/E XECU TI VE D N/A E.L. EAC H ACC IDENT $ 1,000,000 OFF ICER/M EMBER EXCLUDED ? B (Mandatory in NH) A09493503 1/4/2019 1/4/2020 E.L. DISEASE -EA EMPLOY EE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LI MI T $ 1 000 000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101. Add itional Rem arks Schedule , may be attached if more space is required) Project: All California Operations Certificate of Insurance naming The City of Cupertino, its City CoW1cil , boards and commissions, officers, officials, employees, agents, servants and volW1teers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Contractor including materials, parts or equipment furnished in connection with such work or operations as an Additional Insured as required by written contract with respect to work performed by insured. *30 Day Notice of Cancellation for Non-Payment of Premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Cupertino 10300 Torre Ave Cupertino , I ACORD 25 (2014/01) INS025 (201401) CA 95014 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jeff Senigaglia/CF 0~ © 1988-2014 ACORD CORPORATION . All rights reserved . The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006430600 INTERLINE IL 12 01 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY NUMBER POLICY CHANGES Policy Change Number 1 POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000006430600 04/17/19 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE lntegem Inc . K&K Insurance Group , Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES Form CG2404 is added to the Policy Cert# 469 Authorized Representative Signature IL12011185 Copyright , Insurance Services Office , Inc ., 1983 Copyright , ISO Commercial Risk Services, Inc ., 1983 Page 1 of 1 POLICY NUMBER : 606314321 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (Form B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY SCHEDULE Name of Person or Organization; The City of Cupertino, its City Council, boards and commissions, officers, officials, employees, agents, servants and volunteers (If no entry appears above . information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule , but only with respect to liability arising out of your ongoing operations performed for that insured. CG20101093 Copyright. Insurance Services Office , Inc ., 1992 EXHIBITD Contractor's Mandated Reporter Declaration The undersigned does hereby certify that: 1. I am a representative of INTEGEM INC.; that I am familiar with the facts herein and am authorized and qualified to execute this declaration. 2. I declare that INTEGEM INC. has complied with fingerprinting and criminal background investigation requirements with respect to all Contractor's employees who may have contact with minors in the course of providing services pursuant to the Agreement, and the California Department of Justice has determined that none of those employees has been convicted of a felony, as that term is defined in California Penal Code Section 11105.3. 3 . I declare that each coach and administrator shall be required to successfully complete concussion and head injury education at least once, either online or in person, before supervising a participant, as required by California Health and Safety Code Section 124235, et seq. 4. On a yearly basis, all participants shall be required to sign and return a concussion and head injury information sheet in compliance with California Health and Safety Code Section 124235, which may be in the form attached as D-1. 5. That a complete and accurate list of Contractor's employees, who may come in contact with minors during the course and scope of the Agreement, are included below. 6. All of the below mentioned employees have tested negative for TB, or X-ray results for TB, and have current documentation on file with Contractor. 7. All of the below mentioned employees have received training and understand their responsibilities under the Mandated Reporter laws of this state and are willing and able to comply. List of all Contractor Employees working for the City (if no Employees, identify "self"): 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. I declare under penalty of perjury that the foregoing is true and correct. INTEGEM INC. By:~DU Title: CEO Date: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an i1tjury covered by this policy . We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily i1tjury arising out of the operations described in the Schedule where you are required by a written contract to obtain thi s waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. 1. (X) Schedule Specific Waiver Name of person or organization City of Cupertino, its City Council , boards and commissions, officers, officials, employees, agents, servants and volunteers ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2 . Operations: 3. Premium The premium charge for this endorsement shall be percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described . 4 . Minimum premium 5 . Advance Premium All other terms and condition of the policy remain unchanged. (The information below is required to be completed only when this endorsement is issued subsequent to the policy effective date .) Effective March 1, 2019, this endorsement forms part of Policy No . A09493503 Of Issued to: lntegem Inc. AUTHORIZED REPRESENTATIVE