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HomeMy Public PortalAboutC-20-031 - Mediastar, Inc. Amendment No. 1, Audio Visual ServicesAMENDMENT NO. 1 TO AGREEMENT FOR CONTRACT SERVICES THIS AMENDMENT TO THE AGREEMENT FOR CONTRACT SERVICES ("Amendment No. 1 ") by and between the CITY OF CARSON, a California municipal corporation ("City"),and IASTAR INC., a California corporation (``Consultant"), is entered into effective as of the day of May, 2020. RECITALS A. City and Consultant entered into that certain Agreement for Contract Services dated March 17, 2020 ("Agreement") whereby Consultant agreed to provide City services to maintain and operate certain audio/visual equipment and software used for City Council meetings, including those concerning remote interfacing capabilities that became necessary due to the COVID-19 pandemic and State issued guidelines. B. City and Consultant now desire to amend the Agreement to add services for remote management of City Council Special Meetings increasing compensation by $11,250 for a total Contract Sum not to exceed $74,222. TERMS 1. Contract Changes. The Agreement is amended as provided herein (new text in bold italics and deleted text in stfikedffough). a. Section 2. 1, "Contract Sum," of the Agreement is hereby amended to read as follows: "Subject to any limitations set forth in this Agreement, City agrees to pay Consultant the amounts specified in the "Schedule of Compensation" attached hereto as Exhibit "C" and incorporated herein by this reference. The total compensation, including reimbursement for actual expenses, shall not exceed Seventy Four Thousand Two Hundred Twenty Two Dollars ($74,222) Sixty Two Thousand , 4ne Hundred Seventy Two ri,.Rars ($62,-972) ("Contract Sum"), unless additional compensation is approved pursuant to Section 1.8." b. Section V of Exhibit "A" of the Agreement, "Scope of Services," is hereby amended to read in its entirety as follows: ♦ • t+V4Jl114H114 ♦1111 perform all Sefviees (whether ' Seetion 11, Seetion H! or- Seetion 1N7 above) for the City pursuant to the following eonditions, requirements and/or- warranties.! A. /� 4 all f the 1-.f r� t'ivl-.ibit GGA I,!' �I'eeTSPZS���. .S-�Rif0l�il�e��'lam-iI„iCT�GTiITrIPJ T� li V Y 1111d Equipment may be amended �e. - 1 01007.0001/644737.1 Seefien NIL of this Exhibit "A" will per-fet:m all sefviee labef eover-ed by this 1�Y4!rj"! .m!S �TlITS L'L'F - - \WIEM "V. Consultant shall deploy two- staff members to provide remote meeting management services for each City Council Special Meeting. The services will involve pre -meeting setup of recording, audio and external source equipment (currently a Zoom capable PC in the new studio). During the meeting, Consultant's operators will manage the video switching, muting and audio levels. Consultant will also create lower 1/3 graphics to be overlaid on the meeting video and slides for the -2- 01007.0001/644737.1 beginning of the meetings, end of meetings, and closed session meetings, if needed. After the meetings, Consultant shall post -edit the meetings, and trim and fix audio and video issues with the recording and re -encode the meetings. Consultant will send the finished video to the City's video server and will modify the existing schedule to add the meeting to the existing schedule as directed by the Contract Officer. " C. Section V of Exhibit "A" of the Agreement, "Scope of Services," is hereby reunumbered to Section VI and the first paragraph is amended to read in its entirety as follows: "Consultant will perform all Services (whether pursuant to Section I, Section II, Section III, or -Section IV, or Section V above) for the City pursuant to the following conditions, requirements and/or warranties:" d. Sections VI, VII and VIII of Exhibit "A" of the Agreement, "Scope of Services," are hereby renumbered to Sections VII, VIII and IX, respectively. e. Section VI of Exhibit "C" of the Agreement, "Schedule of Compensation," is hereby amended to read as follows: "VI. With respect to the remote Special Meeting services to be provided pursuant to Section V of Exhibit "j," Scope of Services, the City will compensate Consultant for the services performed in an amount not to exceed $11,250." f. Section VI of Exhibit "C" of the Agreement, "Schedule of Compensation," is hereby reunumbered to Section VII and amended to read in its entirety as follows: "The total compensation for the Services (inclusive of Section I, Section II, Section III, Section IV, and Section V of Exhibit "A," Scope of Services) shall not exceed $74,222&S62L,-972, as provided in Section 2.1 of this Agreement." g. Section VII of Exhibit "C" of the Agreement, "Schedule of Compensation," is hereby reunumbered to Section VIII. h. Section IE of Exhibit "D" of the Agreement, "Schedule of Performance," is hereby added as follows: "E. All tasks listed under Section V of Exhibit "A" will be performed by Consultant for each designated City Council Special Meeting currently anticipated to be held twice per month. " -3- 01007.0001/644737.1 m "VI. With respect to the remote Special Meeting services to be provided pursuant to Section V of Exhibit "j," Scope of Services, the City will compensate Consultant for the services performed in an amount not to exceed $11,250." f. Section VI of Exhibit "C" of the Agreement, "Schedule of Compensation," is hereby reunumbered to Section VII and amended to read in its entirety as follows: "The total compensation for the Services (inclusive of Section I, Section II, Section III, Section IV, and Section V of Exhibit "A," Scope of Services) shall not exceed $74,222&S62L,-972, as provided in Section 2.1 of this Agreement." g. Section VII of Exhibit "C" of the Agreement, "Schedule of Compensation," is hereby reunumbered to Section VIII. h. Section IE of Exhibit "D" of the Agreement, "Schedule of Performance," is hereby added as follows: "E. All tasks listed under Section V of Exhibit "A" will be performed by Consultant for each designated City Council Special Meeting currently anticipated to be held twice per month. " -3- 01007.0001/644737.1 2. Continuing Effect of Agreement. Except as amended by this Amendment, all provisions of the Agreement shall remain unchanged and in full force and effect. From and after the date of this Amendment, whenever the term "Agreement" appears in the Agreement, it shall mean the Agreement, as amended by this Amendment to the Agreement. 3. Affirmation of Agreement; Warranty Re Absence of Defaults. City and Consultant each ratify and reaffirm each and every one of the respective rights and obligations arising under the Agreement. Each parry represents and warrants to the other that there have been no written or oral modifications to the Agreement other than as provided herein. Each parry represents and warrants to the other that the Agreement is currently an effective, valid, and binding obligation. Consultant represents and warrants to City that, as of the date of this Amendment, City is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. City represents and warrants to Consultant that, as of the date of this Amendment, Consultant is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. 4. Adequate Consideration. The parties hereto irrevocably stipulate and agree that they have each received adequate and independent consideration for the performance of the obligations they have undertaken pursuant to this Amendment. 5. Authority. The persons executing this Amendment on behalf of the parties hereto warrant that (i) such party is duly organized and existing, (ii) they are duly authorized to execute and deliver this Amendment on behalf of said party, (iii) by so executing this Amendment, such party is formally bound to the provisions of this Amendment, and (iv) the entering into this Amendment does not violate any provision of any other agreement to which said party is bound. [SIGNATURES ON FOLLOWING PAGE] -4- 01007.0001/644737.1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the date and year fir - ve written. C DNS C 4 _ `9�r� CITY: CITY 0 CARSON, ,...,• 9*rt kobles, Mayor ATT Donesia Gause-Aldana,-City Clerk APPROVED AS TO FORM: U ALESHIRE & WYNDER, LLP Sunny K. Soltani, City Attorney (ril) CONSULTANT: MEDT ASTAR INC., a California corporation By: Name`: " DLJ �" See Attached California ��i �2fZ2Q Title: Ail -Purpose Acknowledgement By: Name: L4.�16 C-L.AQ Title: s�Cfi Address: Mcg 2- (N C-- '7a2W,,, ^J;c- 2Z t cOAcO 6,(� 2-6 Two corporate officer signatures required when Consultant is a corporation, with one signature required from each of the following groups: 1) Chairman of the Board, President or any Vice President; and 2) Secretary, any Assistant Secretary, Chief Financial Officer or any Assistant Treasurer. CONSULTANT'S SIGNATURES SHALL BE DULY NOTARIZED, AND APPROPRIATE ATTESTATIONS SHALL BE INCLUDED AS MAY BE REQUIRED BY THE BYLAWS, ARTICLES OF INCORPORATION, OR OTHER RULES OR REGULATIONS APPLICABLE TO CONSULTANT'S BUSINESS ENTITY. -5- 01007.0001f644737.1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document. STATE OF CALIFORNIA COUNTY OF BUTTE On 2020 before me, *A—Vo j�1 `lt (k �►? ersonally ap eared N)W fj. '(aQ,� proved to me on the basis of satisfactory evid ce to be the persory(�) whose name is are subscribed to the within instrument and nowledged to me;thate she/they executed the same in i /h their authorized capacityics<�and that by 5'ecuted /her/their signaturon the instrument the person(< or the entity upon behalf of which the persokiq acted, the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS Vofficial seal. TV. TAFOYA 3 V `� COMM. # 2192103 (�f �� NOTARY PUBLIC - CALIFORNIA +n Signature: BUTTE COUNTY 0 IFO PNS COMM. EXPIRES APRIL 16, 2021- OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER INDIVIDUAL CORPORATE OFFICER 01007.0001/644737.1 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES c1f; _a�. e p` DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE TITLE(S) ❑ PARTNER(S) ❑ LIMITED ❑ GENERAL ❑ ATTORNEY-IN-FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0001/644737.1 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES c1f; _a�. e p` DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document. STATE OF CALIFORNIA COUNTY OF BUTTE Vbu C On 2020 before me, d. M V personally appeared WWC, Cl.��t� , proved to me on the basis of satisfactory evidence to be the perso whose namep(are subscribed to the within instrument and acknowledged to me th he�i /they executed the same in his a /their authorized capacity(�e< and that by his er heir signatureon the instrument the pers006" or the entity upon behalf of which the persoR< acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my haod and official seal.?-A*COMM. COMM. # 2192103 0 .• NOTARY PUBLIC - CALIFORNIA Signature: 2 BUTTE COUNTY 0 � IFOA�� EXPIRES APRIL 16, 2021' OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER INDIVIDUAL ❑ CORPORATE OFFICER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0001/644737.1 DESCRIPTION OF ATTACHED DOCUMENT �P~ C�'O_� \0c; TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES off' o 1� � -W q DATE OF DOCUMENT !'1'K G_ WVrA5 IGNER(S) OTHER THAN NAMED ABOVE TITLE(S) ❑ PARTNER(S) ❑ LIMITED ❑ GENERAL ❑ ATTORNEY-IN-FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0001/644737.1 DESCRIPTION OF ATTACHED DOCUMENT �P~ C�'O_� \0c; TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES off' o 1� � -W q DATE OF DOCUMENT !'1'K G_ WVrA5 IGNER(S) OTHER THAN NAMED ABOVE A� °' CERTIFICATE OF LIABILITY INSURANCE 3 -- ?dz-o 6ATIrjMMtGofiYYY7 THIS CERTIFICATE IS ISSUED ASA 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 border is an ADDITIONAL INSURED, the pollcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the poiicy, 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 Jeff Fowler Insurance Services, INC 426 Broadway #205 Chico, CA 95928 CONTACT NAME: Jeff Fowler PHONE N (530)267-6268 AiXc N, ;(530)167-5555 ENLAIL ADDRESS eff 'fowlerins.com INSURERS AFFORDING COVERAGE HAICt License #: OL07979 INSURER A: Ha for[L[MUrance Company A INSURED MEDIASTAR INC 702 MANGROVE AVE STE 221 CHICO, CA 955926 rNsuRERB: MARKEL INS URAN_CF,-CQQMFAN s tNSURFRc: INSURER D: INSURERE: 0711212020 INSURER F COVERAGES CERTIFICATE NUMBER: 00000000-33550 REVISION NUMBER- A 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO W%KCH THIS CERTIFICATE MAY 13E 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 TR TYPE OF INSURANCE •JIODL 1 UBR POLICY NUMBER POLICY EFF M �P CDY XP LIMITS A X COMMERCLLLGENERALLIABILITY CLAIMS -MADE OCCUR I Y Y 57SBABM0907 07112/2019 0711212020 LEACH OCCURRENCE IS 1,000,000 PREMI occurreme) S 300,000 MED EXP (Any one person) S 5,000 ! PERSON NAL 6 ADV INJURY s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. X POLICY? jECGT. LOC GENERAL AGGREGATE s 2,000,000 PRQOUCTS•COMPPOP AGG S___2,000,{aQ0 Is OTHER: A AUTOOBILE LIABILITY 07/12/2020ECL01.1 SINGLE UMeI 1. 000,000 ANY AUTO OWNED SCHEDULED OAUTO 1. .� BODILY INJURY (Per pnon) S SSS07/12/2019 BODILY INJURY (PeT acrident)AUTOS HIRED NON•OVVNEO AUTOSONLY AUTOS ONLY PROPERTYDAMAGE ' era en S UMBRELLALIAB OCCUR (j! EACH OCCURRENCE S AGGREGATE s LII B CLAIM&MADE ( NEXCESS RETENTIONS S I B WOR CDMPENSATION AND EMPLDYERS'LIABILITY YIN ANY PROPMETORMARTNEWEXECUTWE OFFICEPIAEMBER EXCLUDED? M (Mandalcry,n NHI It ns, desrnbe under DESCRIPTIONOFOPERATIONS below j N I A ttt I I Y MWC0154455-01 10811512019 i 08/1512020 I ; r I P H• X I rAT r-'^"`^"' E L. EACH ACCIDENT S 1,0001000 EL DISEASE• EA EMPLOYEE S1,Q00,000 E. L. DISEASE• POLICY LIMIT I S 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATtONS l VEHICLES (ACORO tat, Additional RamaTln Schedule, may be atuched (I more spate Is nqubed) 1, City of Carson, Its elected and appointed officers, employees, volunteers and agents are additional insureds on GE and Auto policies. 2. GL policy is Primary and Non-contributory. 3. Waiver of Subrogation endorsement in favor of City of Carson OR in favor of additional insured. CITY OF CARSON 701 E Carson Street CARSON, CA 90745 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE 15 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Printed by JRF on October 22, 2019 at 03 43PM F1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below; Policy Number: 57 SBA BM0907 SC Named Insured and Mailing Address; MEDIASTAR INC 702 MANGROVE AVE STE 221 CHICO CA 95926 Policy Change Effective Date: 1.0/23/19 Policy Change Number: 002 Agent Name: NETWORKED INSURANCE AGENTS LLC Code: 121637 Effective hour is the same as stated in the Declarations Page of the Policy. POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLIN STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL, ADDITIONAL PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE: $26.00 'INCLUDES ADDITIONAL TERRORISM PREMIUM OF: $1.00 LOCATION 001 BUILDING 001 IS REVISED PRO RATA FACTOR: 0.721 THIS ENDORSEMENT DOES NOT CHANGE TIME POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page 001 (CONTINUED ON NEXT PAGE) Process Date: 10/23/19 Policy Effective Date: 07/12/19 Policy Expiration Date: 07/12/20 POLICY CHANGE (Continued) Policy Number: 57 SOA BM0907 Policy Change Number: 002 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED: FORM SS 12 15 LOCATION 001 BUILDING 001 CITY OF CARSON 701 E CARSON ST CARSON, CA 90745 FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED - PERSON -ORGANIZATION FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: SS 12 15 03 00 Form SS 1211 04 OS T Page 002 Process Date: 10/23/19 Policy Effective Date: 07/12/19 Policy Expiration Date, 07/12/20 POLICY PLUMBER: 57 SAA SM0907 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION THE CITY OF TRACY (INCLUD ING ITS ELECTED OFFICIALS, OFFICERS, EMPLOYEES, AGENTS, AND VOLUNTEERS) 333 CIVIC CENTER PLAZA TRACY, CA 95376 CITY OF CARSON 701 E CARSON ST CARSON, CA 90745 Form IH 12 00 1186 T SEQ. NO. 001. Printed in U.S.A. Page 001 Process Date: 10/23/19 Expiration Date: 07/12/20 THIS ENDORSEMENT CHANGI=S THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION This endorsement modifies insurance provided under the Following: BUSINESS LIABILITY COVERAGE FORM We waive any right of recovery we may have against: 1. Any person or organization shown in the Declarations, or 2. Any person or organization with whom you have a contract that requires such waiver. Form SS 12 15 03 00 0 2000, The Hartford Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY INFORMATION PAGE ENDORSEMENT The following item(s) Insured's Name (WC 89 06 01) Policy Number (WC 89 06 02) Effective Date (WC 89 06 03) Expiration Date (WC 89 06 04) InStrred's Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer's Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured's Legal Status (WC 89 06 10) Item 3.A, States (WC 89 06 11) is changed as follows: Action Tyne Prcttous valuc Item 3.B. Limits (WC 89 06 12) Item 3.C. States (WC 89 06 13) X Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4. Class, Rate, Other (WC 89 04 15) Interim Adjustment of Premium (WC 89 04 16) WC 89 06 00 B Carrier Servicing Office (WC 89 06 17) Interstatellntrastate Risk ID Number (WC 89 06 18) Carrier Number (WC 89 06 19) Issuing Agency/Producer Office Address (WC 89 06 25) Nuu Value (Ed 7-01) Add 1Val.cr of WA rypc individual Suhrop,atton state CA Class Code 8859 Payroll 0 Suhtogant Nutne CITY OF CARSON Subrogant Address 701 E Carson Street SuhrugantCity CARSON Stale CA Postal Codc 90745 EfTective Date 10/22/2014 Exptratton Date 0ffi'13t1-00 Total Estimated Annual Premium $625.00 Premium Adjustment $362.00 Minimum Premium $ 23.00 Deposit Premium $643.00 All other terms and conditions of this policy remain unchanged, This endorsement changes the pol cy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 10122/2019 Policy No MWC0154455-01 Endorsement No. Insured: mediastar inc Premi im (See Attached) Insurance Company Markel Insurance Company Countersigned by WC8906000 Ed, T-01 O 2D01 National Cojacsl on Coropcnslto ,nsuramce Inc IN111IC1I111,111 [11111111Elm 1111111 of ill�aill�ll�lllll��l��l[�[�111111�1�1�1�11111� 004T19 01348646250843.10232010 MAK:015445..: I MARKEL INSURANCE COMPANY A STOCK COMPANY TEN PARKWAY NORTH ������ DEERFIELD, IL 60415 800-431-1270 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI No. 22616 New No. State Unemployment I.D. No. or Identifying Number as Required: 1. Insured: mediastar inc dba Mailing 702 Mangrove Ave Ste 221 Address Chico, CA 95926-3948 Email Address: davep2006@mediastar-sg.com Individual ElPartnership Policy No. MWC0154435-01 Renewal of Policy Number New FEIN: 205785590 Producer. Jeff Fowler Insurance Services Mailing 426 Broadway St Ste 205 Address Chico, CA 95928 I " t Corporation or EJ Other workplace not shown above: See Attached Location Schedule 2. Policy Period: The policy is from 0811312019 to 0811512020 [12.01 AM Standard Time] at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: CALIFORNIA B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury- by Accident: Bodil} Injure by Disease_ Bodily Injure- by Disease: S 1,t10t1,(10ti each accident 5 1,00(),0(}0 policy limit 5 i,000,IlOf1 each employee C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here: All states except those listed in Item 3A of the Information Page and the following states or territories: District of Columbia, ID, MT, NY, ND, OH, OR, WA, WY, Puerto Rico and US Virgin Islands. D. This Policy includes these endorsements and schedules: MDWCl000A, MJWC1000, MPIL 1007, MPIL 1083, 1vfPWC10000510, MWC 1202 -CA, MWC12000510, MWC 140305 10, NIWC140405 10, PN04990IG, PN049902B, PN049904, WCOOOOOOC, WC000419, WC00042213, WC040002, WC040003, WC040004, WC040005, WC040301D, WC040303C, WC040306, WC040360B, WC040601A, WC890600B 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Classification No Estimated Annual $100 of Estimated Annual Premium Remuneration Remuneration See WC 04 00 05 Extension of Information Page MINIMUM PREMIUM $23.00 TOTAL ESTIMATED ANNUAL PREMIUM $625.00 TAXES & ASSESSMENTS $18.00 IF INDICATED BELOW, INTERIM ADJUSTMENTS OF PREMIUM SHALL BE MADE: X Annually Semi -Annually Quarterly Monthly $643.00 Deposit Premium $Per Installment Endr Issuing Office: Omaha, Nebraska Countersigned by, NIDWC 1000A (06/15) 209 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 02 (Ed. 7-98) EXTENSION OF INFORNIATION PAGE Schedule of Name Insured ITEM I Policy No. MWC0154455-01 Name Insured mediastar inc 0 1998 by the Workers' Compensation Insurance Rating Bureau at Callomia All rights reserved. From the WCIRB's California Workers Compensation Insurance Forms Manual 0 2001. 3 of 9 FEIN 205785590 WOIW,'RS C'OIIHNS: TION AIM) EMPLOVERS LL%BILIT1' INSt3L%NCE PO[,[('1' EXTENSION OF INFORMATION PAGE Schedule of Locations ITEM i WC 04 00 03 (Ed. 7 9S) Policy No, MWC0154455-01 Location FEIN PHONE sic ENTITY TYPE CODE 1 702 Mangrove Ave Ste 221 205785590 530-898-9588 7371 Corporation Chico, CA 95926-3948 ©1998 by the Workers' Compensation Insurance Rating Bureau of California, Ad rights reserved, From the WCIR9's California Workors' Componsabon Insurance Forms Manual O 2W1, 4 of 9 11 oRKEMS C011P1a\S;1'['10\ AND E )II'1.01` '.1151,118[t.t'i'1' ItiN1'[UNCG P01.10' %VC01 W 04 (Ed. 7 98) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D Policy No. M1WC0154455-01 Form Numbers Aunficahle States MIDWCIOOOA, MJWC1000. M1P1L 1007, MPIL 1083, MIPWC10000510, MWC 1202 -CA, MWC12000510, M11'C 14030510, M WC 140`10510, PN049901 G, PN04990213, PN049904, WC000000C, WC000419, WC000422B, CALIFORNIA WC040002, WC040003, WC040004, WC040005, WC040301 D, WC040303C, WC040306, WC040360B, WC040601 A, WC890600B m 1998 by 1ho Workers' Ccmpensalion Insurance Rating Bureou of Colilemia All rights reserved From the WCIRB's California Workers Compensation Insurance Forms Manta' C 2001 - 5 0f 9 WORKERS COMPENSATION AND EMPLOYERS UUi ATI INSURUtiCL POLICY WC 04 oil 05 (Fd. 7 M EXTENSION OF INFORNTATION PACE Classifications ITEM 4 Policy No. MWC0154455-01 Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual Code Classification Remuneration Remuneration Premium 8859 Computer Programming Or $0.00 0.130 $0.00 Software Development Total Amount Due $0,00 If you elect a payment plan, then you will be subject to installment fees for each payment ranging from S3-$10 depending on the state. if you elect electronic funds transfer, these fees will not apply. ;1998 by the Workers` Compensation Insurance Rating Bureau of California. All rights reserved. From tho WCIRB's Colifornm VLbrkers' Compensation Insuranco Forms Manual 2801 6of9 AVORK11"Its CONIPF.`'SATHYN AND ti:MPLOl'ERS I.[NHILM' LNSVRANVE` . P01 -1C1 - EXTENSION OF INFORINIATION PAGE Classifications ITEM 4 Code Classification 8859 Computer Programming Or $100 of Software Development 0930 Waiver Premium Subject Premium 0.130 Total Subject Premium Modified Premium 9889 Schedule Rating Standard Premium 0900 Expense Constant $250.00 Estimated Annual Premium WC Admin Revolving Assessment $125-00 Fraud Surcharge UEBTFA Subsequent Injury Fund $250.00 Occupation Safety and Health Fund Surcharge Labor Enforcement and $9.00 Compliance Fund Surcharge 0.288 Total Amount Due MC0-t011115(ii.7-") Policy No. MWC0154455-01 Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual Remuneration Remuneration Premium $0-00 0.130 S€1.00 5.000 $250.00 $250.00 $250.00 $250.00 0.500 $125-00 $375,00 $250.00 $625.00 1.448 $9.00 0.288 $2.00 0.083 $1,00 0,274 $2.00 0.377 $3.00 0.343 $2.00 $643.00 Ifyou elect a payment plan, then you will be subject to installment fees for each payment ranging from S3 -SIO depending on the state. If you elect electronic funds transfer, these fees will not apply. t? 1998 by the Workers' Compensat,on Insurance Rating Bureau of California. Al': rights reserved From the WOR6's California Worirors Campensation insurance Forms MasuW V 2001 7oi4 MARKEL INSURANCE COMPANY Installment Endorsement It is hereby agreed and understood that the premium is to be paid on an installment basis as follows: Premium: $625.00 Fees: S 18.00 Deposit: $643.00 Installments Taxes & Surcharees 1.08/15/2019 $643.00 included If you elect a payment plan, then you will be subject to installment fees for each payment ranging from $3-S10 depending on the state. If you elect electronic funds transfer, these fees will not apply, This endorsement is effective: 10/22/2019 forms a part of Policy: NINVC0154455-01 Dated: 10/23/2019 Issued to: mediastar inc By: Markel Insurance Company All other terms and conditions of this policy remain unchanged. 8of9 MWC 1200 05 10 WORKERS COMPENSATION ANIS EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 % of the Califomia workers' compensation premium otherwise due on such remuneration. Work performed by mediastar inc at 702 Mangrove Ave 'Chico, CA 95928-3948 Subrogant Information Class Code CITY OF CARSON 701 E Carson Street 8859 CARSON, CA 90745 Schedule Description Computer Programming Or Software Development This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 10/22/2019 Policy No MWC0154455-01 Endorsement No Insured mediastar inc Premium (See Attached) Insurance Company; Markel Insurance Company Countersgned by =040306 (Ed. 04-84) 0 '1998 by the workers Compensation insurance Rating Bureau of Ca1omia AS rights reservorl. From the WORS'sCalifornia Workays• CompennalionInsurance Forms Manual 92041 9ot9 Payroll $000