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HomeMy Public PortalAboutC-23-050 - UC ADVANTAGE AMENDMENT NO. 1, 2023 MARCH 09AMENDMENT NO. 1 TO CONTRACT SERVICES AGREEMENT THIS AMENDMENT NO. 1 TO THE AGREEMENT FOR CONTRACT SERVICES ("Amendment No. 1") by and between the CITY OF CARSON, a California municipal corporation ("City") and UC ADVANTAGE, INC., a California corporation ("Consultant") is dated the 1st day of October, 2022. RECITALS A. On May 12, 2021, City and Employers Group Service Corp., a California corporation ("Employers Group"), entered into an Agreement for Contract Services ("Agreement"), whereby Employers Group agreed to provide unemployment insurance claims administration services for 3 years for a total not -to -exceed contract sum of $8,700.00 per year. B. Employers Group desires and intends to assign all of its rights, interests, duties and obligations under the Agreement to Consultant (UC Advantage, Inc.), and Consultant sees fit to assume the same. To that end, Employers Group provided City with an email on June 14, 2022, expressing Employers Group's intent to transfer its rights and responsibilities under the Agreement to Consultant. Consultant has not yet formally agreed to assume the Agreement nor the rights, interests, duties and obligations thereunder. C. Section 4.3 of the Agreement provides that "neither this Agreement nor any interests herein may be assigned or transferred, voluntarily or by operation of law, without prior written approval of City." Accordingly, neither Employers Group's assignment of its rights, interests, duties and obligations under the Agreement to Consultant, nor Consultant's assumption of the same, may be effectuated without City approval. However, the City is amenable to the requested assignment and assumption, as is Consultant. Therefore, the City and Consultant now see fit to enter into this Amendment No. 1 to add an exception to Section 4.3 of the Agreement to authorize a transfer and assignment of Employer Group's rights, interests, duties and obligations under the Agreement to Consultant, and Employers Group acknowledges and consents to same. D. Based on the foregoing, City and Consultant now desire and intend to amend the Agreement to authorize the assignment of the Agreement from Employers Group to Consultant, and the assumption of the Agreement by Consultant, and to thereby authorize and require the performance of the services under the Agreement by Consultant commencing as of said date, but only provided that Consultant formally agrees to assume the Agreement and the rights, interests, duties and obligations, thereunder, by entering into an appropriate assignment and assumption agreement with Employer's Group ("Assignment and Assumption Agreement"). Accordingly, this Amendment No. 1 will not got into effect until such time that the Assignment and Assumption Agreement is duly approved and executed. TERMS 1. Recitals. The foregoing recitals are true and correct and are incorporated herein by reference. -1- 01007.0001/807308.3 2 2. Contract Changes. The Agreement is amended as provided herein (new text is identified in bold italics, deleted text in strilcethfeugh): A. Section 4.1, "Representative of Consultant," is hereby amended to read in its entirety as follows: "William C. Stephens is hereby designated as being the representative of Employers Group Services, Inc. authorized to act on its behalf with respect to the work and services specified herein and make all decisions in connection therewith from the date of the Agreement through the date this Agreement is assigned to and assumed by UC Advantage, Inc., a California corporation,. Jason E. Hayek, President is hereby designated as being the representative of Consultant authorized to act on its behalf with respect to the work and services specified herein and make all decisions in connection therewith, effective the date this Agreement is assigned to and assumed by UC Advantage, Inc., a California corporation. All personnel of Consultant and any authorized agents shall be under the exclusive direction of the representative of Consultant. Consultant shall utilize only competent personnel to perform services pursuant to this Agreement. Consultant shall make every reasonable effort to maintain the stability and continuity of Consultant's staff and subcontractors, and shall keep City informed of any changes." B. Section 4.3, "Prohibition Against Subcontracting or Assignment," is hereby amended to read in its entirety as follows: "Consultant shall not contract with any entity to perform in whole or in part the work or services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of the City. Any such prohibited assignment or transfer shall be void. Notwithstanding the foregoing, and as a sole exception thereto, City approves of the assignment and transfer of the Consultant's rights, interests, duties, and obligations under this Agreement from "Employers Group Services, Inc.," a California Corporation, to "UC Advantage, Inc." a California Corporation, as requested and agreed to by said parties." C. The Agreement is hereby amended to change the name of the Consultant such that the term "Consultant," and all references to "Employers Group Services, Inc., a California Corporation," as used in the Agreement, shall be construed to mean and refer to "UC Advantage, Inc., a California Corporation." D. Section IV. of Exhibit A, "Scope of Services," is hereby amended to read in its entirety as follows: "Consultant will utilize the following personnel to accomplish the Services for the period of May 12, 2021 through the date this Agreement is assigned to and assumed by UC Advantage, Inc., a California corporation: A. Marquita Smith (Claims Administrator) -2- 01007.0001/807308.3 B. Madison Apodaca (Claims Manager) C. William C. Stephens (Client Service Director) D. Hearing representatives assigned by the Consultant on a case -by -case basis. To the extent hearing representatives are Consultant's independent contractors and not employees, Consultant is fully responsible for ensuring that work performed by such independent contractors are in compliance with this Agreement." E. A new Section V. is hereby added to Exhibit A, "Scope of Services," to read in its entirety as follows: "Consultant will utilize the following personnel to accomplish the Services, effective the date this Agreement is assigned to and assumed by UC Advantage, Inc., a California corporation: A. Christina Swedberg, UI Claims Analyst & Hearing Coordinator B. Valerie Chitty, Director of Operations C. Ashley Widdison, Tax Specialist & Account Support D. Erica Howe, Power of Attorney Manager E. Melissa Barker, VP, Executive Operations & Power of Attorney F. Gary Acosta, Director of IT G. Jason Hynek, CEO & Account Executive" 3. Effective Date of Amendment No. 1. City and Consultant agree that this Amendment No. 1 will not go into effect until such time that the Assignment and Assumption Agreement is duly approved and executed. If the Assignment and Assumption Agreement is not executed by December 31, 2022, this Amendment No. 1 will be void ab initio and will be deemed as though it was never entered into in the first place. 4. Continuing Effect of Agreement. Except as amended by this Amendment No. 1, all provisions of the Agreement shall remain unchanged and in full force and effect. From and after the date of this Amendment No. 1, whenever the term "Agreement" appears in the Agreement, it shall mean the Agreement, as amended by this Amendment No. 1 to the Agreement. 5. 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 party represents and warrants to the other that there have been no written or oral modifications to the Agreement other than as provided herein. Each party represents and warrants to the other that the Agreement is currently an effective, valid, and binding obligation. -3- 01007.0001 /807308.3 Consultant represents and warrants to City that, as of the date of this Amendment No. 1, 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 No. 1, 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. 6. 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 No. 1. 7. Authority. The persons executing this Amendment No. 1 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 No. 1 on behalf of said party, (iii) by so executing this Amendment No. 1, such party is formally bound to the provisions of this Amendment No. 1, and (iv) the entering into this Amendment No. 1 does not violate any provision of any other agreement to which said party is bound. [signatures on the following page] -4- 01007.0001/807308.3 IN WITNESS WHEREOF, the parties hereto have executed this Amendment No. 1 on the date and year first -above written. CITY: CITY CAF CARSON, a municipal corporation A.) Davis -Holmes, Mayor ATTEST: Dr. Khaleah K. Bradshaw, City Clerk APPROVED AS TO FORM: ALESHIRE & WYNDER, LLP Sunny K. Soltani, City Attorney [ndp, rjl] CONSULTANT: UC Advantage, Inc., a Californiacorporatio By: ason E. Jaayrrec i CEO Titl : President 14-4147e/< By: ' j AS cri.,I j.- - Name: Title: G () Address: 15 Enterprise, Suite 420 Aliso Viejo, CA 92656 -5- 01007.0001/807308.3 IN WITNESS WHEREOF, the parties hereto have executed this Amendment No. 1 on the date and year first -above written. CITY: CITY OF CARSON, a municipal corporation Lula Davis -Holmes, Mayor ATTEST: Dr. Khaleah K. Bradshaw, City Clerk APPROVED AS TO FORM: ALESHIRE & WYNDER, LLP Sunny K. Soltani, City Attorney [ndp, rjl] CONSULTANT: UC Advantage, Inc., a Californiacorporatio By: am- ason E. Titl-: President ek& CEO tiveK By: Jl*5oz1 11-11 Aft 42 i(_ Name: Title: Address: 15 Enterprise, Suite 420 Aliso Viejo, CA 92656 -5- 01007.0001/807308.3 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 f<r,M 2022 before me, Cc. wi , personally appeared .1 j-ob Hype On yrek , proved to me on the basis of�satisfactory evidence to be the pers ci whose name /are subscribed to the within instrument and acknowledged to me t at 'she/they executed the same in er/their authorized capacity(i , and that by /her/their signature on the instrument the person(X, or the entity upon behalf of which the persorj acted, executed the instrume t I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: NATE CUNNINGHAM Notary Public - California [ Orange County Commission # 2337621 My Comm. Expires Nov 16, 2024 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 0 CORPORATE OFFICER 0 TITLE(S) PARTNER(S) 0 LIMITED 0 GENERAL ATTORNEY -IN -FACT TRUSTEE(S) GUARDIAN/CONSERVATOR OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0001/807308.3 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE ACKNOWLEDGED AND CONSENTED TO: Employers Group Services, Inc., a California corporation: By: Name: Mark Wilbur Title: President & CEO Name: William C. Stephens Title: Secretary Address: 400 North Continental Blvd. Suite 300 El Segundo, CA 90245 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. 6 01007.0001/807308.3 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 LOS ANGELES (' On G1 2 , 2022 before me, J A -r, personally appeared! 4? i' A-1116,..; ,_proved to me 011 the basis of satisfactory evidence to be the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) 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. BRUNO SARTINI JR WITNESS my lei official seal. Signature: COMM. #2413947 - H NOTARY PUBLIC • CALIFORNIA LOS ANGELES COUNTY Commission Expires AUGUST 25, 2026 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 ❑ CORPORA 1'E OFFICER TITLE(S) PARTNER(S) ❑ LIMITED 0 GENERAL ATTORNEY -IN -FACT TRUSTEE(S) GUARDIAN/CONSERVATOR OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DA 1'E OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE 01007.0001/807308.3 ACK7NOWLEDGETI AND CONSENTED TO: Employers Group Services, Inc., a California corporation: 13u; Name: Mark Wilbur Title: President & CEO c Name: William C. Stepheifs Tine: Sec_r :a s J; Address: 400 North Continental Blvd. Suite 300 El Segundo, CA 90245 Iwo corporate officer signatures required when "Consultant is a corporation, -with oue signature reyuirei 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 I'M; BYLAWS, ARTICLES OF INCORPORATION, OR OT7IER RULES OR REGULATIONS APPLICABLE TO CONSULTANT'S BUSINESS ENTITY. 01007.0001/807308.3 CAL -. ORNIA ALL-Pu"cP S A `10OW'Lf.;DG MENT 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. STA 1'h OF CALIFORNIA .z.1s � v ¢M � �.� Cvl e On 0 1 , 2022 before me,, ° a 17(0 rsonally a eared � , proved to me on the basis of satisfactory evidence t e the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. 1 certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ROYA KHOSROABADI Notary Public • California Ventura County Commission # 2336750 My Comm, Expires Nov 12, 2024 OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could ViE411[+UIFLii t'illti 'this 1L%L ldl. CAPACITY CLAIMED BY SIGNER ❑ INDIVIDUAL ❑ CORPORATE OFFICER TITLE(S) ❑ PARTNER(S) ❑ LIMITED ❑ GENERAL Lj ATTORNEY -IN -FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR D OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) DESCRIPTION OF ATTACHED DOCUMENT TI'CLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE t i007.0CR; I*073t r.3 iinAmmuuumiiuiiii iinuimniumuunuumuiiunuiumiimummiimuumii STATE OF CALIFORNIA Office of the Secretary of State STATEMENT OF INFORMATION CORPORATION California Secretary of State 1500 11th Street Sacramento, California 95814 (916) 653-3516 For Office Use Only -FILED- File No.: BA20220953318 Date Filed: 10/7/2022 Entity Details Corporation Name UC ADVANTAGE, INC. Entity No. 2756578 Formed In CALIFORNIA Street Address of Principal Office of Corporation Principal Address 15 ENTERPRISE SUITE 420 ALISO VIEJO, CA 92656 Mailing Address of Corporation Mailing Address 15 ENTERPRISE, SUITE 420 ALISO VIEJO, CA 92656 Attention Amy McPeek Street Address of California Office of Corporation Street Address of California Office 15 ENTERPRISE, SUITE 420 ALISO VIEJO, CA 92656 Officers Officer Name Officer Address Position(s) • JASON EDWARD HYNEK 15 ENTERPRISE, SUITE 420 ALISO VIEJO, CA 92656 Chief Executive Officer, Secretary, Chief Financial Officer Additional Officers Officer Name Officer Address Position Stated Position None Entered Directors Director Name Director Address • Jason Edward Hynek 15 ENTERPRISE, SUITE 420 ALISO VIEJO, CA 92656 The number of vacancies on Board of Directors is: 0 Agent for Service of Process Agent Name MARK L EISENHUT Agent Address 610 NEWPORT CENTER DRIVE, SUITE 700 NEWPORT BEACH, CA 92660 Type of Business Type of Business MANAGEMENT CONSULTING Email Notifications Opt -in Email Notifications Yes, I opt -in to receive entity notifications via email. Labor Judgment No Officer or Director of this Corporation has an outstanding final judgment issued by the Division of Labor Standards Enforcement or a court of law, for which no appeal therefrom is pending, for the violation of any wage order or provision of the Labor Code. L6 CO 0 0 0 N rn Page 1 of 2 Electronic Signature ® By signing, I affirm that the information herein is true and correct and that I am authorized by California law to sign. Amy McPeek 10/07/2022 Signature Date ZZOZ/LO/OT T89L-6STTg Received by California Secretary of State Page 2 of 2 l� Employment EDD Development Department State California POWER OF ATTORNEY (POA) DECLARATION SEE INSTRUCTIONS ON THE BACK OF THIS FORM. 1. EMPLOYER/TAXPAYER INFORMATION (please type or print) California Employer Payroll Tax Account Number: (if applicable) 944-0013-2 Federal Employer Identification Number: 95-2513547 Owner/Limited Liability Company/Limited Partnership/Corporation Name: Corporate/Limited Liability Company/Limited Partnership Identification Number: Business Name/Doing Business As (DBA): CITY OF CARSON Business Mailing Address: City: State: ZIP Code: 701 E. CARSON ST. CARSON CA 90746 Business Phone Number: Business Fax Number: Business Location (if different from above): City: State: ZIP Code: II. REPRESENTATIVE DESIGNATION (please type or print) I hereby appoint the following person to represent the employer/taxpayer for specified tax matters arising under the California Unemployment Insurance Code. Representative's Business: UC ADVANTAGE, INC. Representative's Name: Melissa Barker Phone Number: (800) 391-5128 Fax Number: (308) 244-4014 Business Mailing Address: PO BOX 280 City: State: ZIP Code: NORTH PLATTE NE 69103 III. AUTHORIZED ACT(S) ❑ GENERAL AUTHORIZATION: If you want to give the representative general authority to perform all acts on your behalf with regard to your state tax matters. WI SPECIFIC DECLARATION: If you want to give the representative limited authority with regard to your state From To wrirtal o on tax matters, indicate the specific dates and acts you are authorizing. m To represent the employer/taxpayer for any and all ❑Tax reporting. ❑ Benefit reporting. m Both matters relating to the reporting period indicated above. m To represent the employer/taxpayer for changes to their mailing address for any and all ❑Tax reporting. ❑ Benefit reporting. m Both matters relating to the reporting period indicated above. m Other acts: (describe specifically) claims, benefits, charges, determinations, hearings, tax rate notices m Subject to revocation, the above representative is authorized to receive confidential information. IV. SIGNATURE AUTHORIZING POWER OF ATTORNEY Signature of the employer/taxpayer, owner, officer, receiver, administrator, or trustee for the employer/taxpayer: If you are a corporate officer, partner, guardian, tax matters partner/person, executor, receiver, administrator, or trustee on behalf of the employer/taxpayer, you are certifying that you have the authority to execute this form on behalf of the employer/taxpayer by signing this Power of Attorney Declaration. If this Power of Attorney Declaration is not signed and dated, it will be returned as invalid. I certify under penalty of perjury that the above information is true, correct, and complete, and that these actions are not to be taken to r ve a more favorable Unemployment Insurance rate. I further certify that I have the authority to sign on behalf of the above business. SSirr -O.-L gar City Manager igriature Title (Owner, Partner, Corp. Officer: Pres., Vice Pres., CEO or CFO) David C Roberts. Print Name Date (� �j- Z3 DE 48 Rev. 10 (12-19) (INTERNET) Page 1 of 2 CU Instructions for Completing the Power of Attorney (POA) Declaration (DE 48) General Information This DE 48 is your written authorization for an individual or other entity to act on your behalf in tax and/ or benefit reporting matters, and will remain in effect until it is rescinded or revoked. When a new POA is filed with the Employment Development Department (EDD), the new POA will automatically revoke any prior declaration(s) on file unless you attach a copy of each POA that you want to remain in effect. In addition, if you need to limit the term of a POA, you must specify the date it will expire as outlined in Section III below. For general information, call the Account Services Group at 1-916-654-7263. I. EMPLOYER/TAXPAYER INFORMATION - Enter your California employer payroll tax account number (if applicable), federal employer identification number, owner or corporation name, corporate identification number, business name/doing business as (DBA), mailing address, business phone and fax number(s), and business location if different than the mailing address. II. REPRESENTATIVE DESIGNATION - Enter the representative's business, representative's name, phone number, fax number, and address. III. AUTHORIZED ACT(S) - If you want to authorize your representative to perform any and all acts on your behalf, check the "General Authorization" box. If you want to limit this authorization, check the boxes that apply under "Specific Declaration." Enter the beginning and ending dates of each interval/period for which you are making the declaration. IV. SIGNATURE AUTHORIZING POWER OF ATTORNEY - The POA must be signed and dated by the business owner, partner, or corporate officer (i.e., President, Vice President, CEO, or CFO). Please submit an updated list of corporate officers/owners with this document, if applicable. If the declaration is submitted without a signature or with an unauthorized signature, it will be returned. Please return your completed DE 48 to the EDD at: Employment Development Department Account Services Group, MIC 28 PO Box 826880 Sacramento, CA 94280-0001 Fax 1-916-654-9211 You can also electronically submit a POA using e -Services for Business. If you have questions or need assistance completing this form, please call the Account Services Group Agent Line at 1-916-654-7263. DE 48 Rev. 10 (12-19) (INTERNET) Page 2 of 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 confer rights to the certificate holder in lieu of such endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 1/23/2023 HUB International Insurance Services Inc. 401 Fremont Street Suite 100 Monterey CA 93940 Corena Serrano-Navarro 831-642-4007 831-920-0108 corena.serrano@hubinternational.com License#:0757776 Ohio Security Insurance Company 24082 UCADVAN-01 American Fire and Casualty Company 24066UCAdvantageInc 15 Enterprise Ste 420 Aliso Viejo CA 92656 Certain Underwriters at Lloyds Capitol Specialty Insurance Corporation 10328 Hanover American Insurance 36064 398958950 A X 1,000,000 X 1,000,000 15,000 1,000,000 2,000,000 X X Y BZS58534157 2/13/2023 2/13/2024 2,000,000 A 1,000,000 X X BZS58534157 2/13/2023 2/13/2024 B X 1,000,000 X ESA58534157 2/13/2023 2/13/2024 1,000,000 E XWZFJ007743007/15/2022 7/15/2023 1,000,000 1,000,000 1,000,000 D C E &O (Retro Date:6/8/20) Cyber SGC001162301 MPL218659322 6/8/2022 5/1/2022 6/8/2023 5/1/2023 Deductible:$25,000 Retention:$2,500 1,000,000 1,000,000 RE:Work performed by the named insured as required by written contract. Additional Insured:City of Carson,its elected and appointed officers,employees,volunteers and agents as required by written contract Forms:BP 79 96 09 16 City of Carson 701 E Carson Street Carson CA 90745 13 2 1 9 4 of BUSINESSOWNERS BP 79 96 09 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASEREAD IT CAREFULLY. BUSINESSOWNERS LIABILITY EXTENSION ENDORSEMENT 2016 Liberty Mutual Insurance BP 79 96 09 16 Page 1 of 4Includes copyrighted material of Insurance Services Office, Inc.,with its permission. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGEFORM Below is a summarization of the coverages provided by this endorsement. No coverages are given by this summary. Actual coverage descriptions are within this endorsement. SECTION SUBJECT A.Supplementary Payments Bail Bonds Loss Of Earnings B.Broadened Coverage For Damage To Premises Rented To You C.Incidental Medical Malpractice Injury D.Mobile Equipment E.Blanket Additional Insured (Owners, Contractors Or Lessors) F.Newly Formed Or Acquired Organizations G.Aggregate Limits H.Duties In The Event Of Occurrence, Offense, Claim Or Suit I.Liability And Medical Expenses Definitions Bodily Injury Insured Contract Personal And Advertising Injury Section II - Liability is amended as follows: A. Supplementary Payments Section A.1. Business Liability is modified as follows: 1.The $250 limit shown in Paragraph A.1.f.(1)(b) Coverage Extension - Supplementary Payments for the cost of bail bonds is replaced by a $3,000 limit. 2.The $250 limit shown in Paragraph A.1.f.(1)(d) Coverage Extension - Supplementary Payments for reasonable expenses and loss of earnings is replaced by a $500 limit. B. Broadened Coverage For Damage To Premises Rented To You 1.The last paragraph of Section B.1. Exclusions - Applicable To Business Liability Coverage is replaced by the following: With respect to the premises which are rented to you or temporarily occupied by you with the permis- sion of the owner, Exclusions c., d., e., g., h., k., l., m., n.and o.do not apply to "property damage". 13 3 1 9 4 of 58 5 3 4 1 5 7 00 2 1 7 4 28 0 2016 Liberty Mutual Insurance BP 79 96 09 16 Page 2 of 4Includes copyrighted material of Insurance Services Office, Inc.,with its permission. 2.Paragraph D.2. Liability And Medical Expenses Limits Of Insurance is replaced by the following: The most we will pay under this endorsement for the sum of all damages because of all "property damage" to premises while rented to you or temporarily occupied by you with the permission of the owner is the Limit of Insurance shown in the Declarations. 3.Paragraph D.3. Liability And Medical Expenses Limits Of Insurance does not apply. C. Incidental Medical Malpractice Injury 1.Paragraph (4)under Paragraph B.1.j. Exclusions - Applicable To Business Liability Coverage - Profes- sional Services does not apply to "Incidental Medical Malpractice Injury" coverage. 2.With respect to this endorsement, the following is added to Section F. Liability And Medical Expenses Definitions: a."Incidental Medical Malpractice Injury" means bodily injury arising out of the rendering of or failure to render, during the policy period, the following services: (1)Medical, surgical, dental, x-ray or nursing service or treatment or the furnishing of food or beverages in connection therewith; or (2)The furnishing or dispensing of drugs or medical, dental or surgical supplies or appliances. b.This coverage does not apply to: (1)Expenses incurred by the insured for first-aid to others at the time of an accident and the Duties in the Event of Occurrence, Offense, Claim or Suit Condition is amended accordingly. (2)Any insured engaged in the business or occupation of providing any of the services described under a.above. (3)Injury caused by any indemnitee if such indemnitee is engaged in the business or occupation of providing any of the services described under a.above. D. Mobile Equipment Section C. Who Is An Insured is amended to include any person driving "mobile equipment" with your permission. E. Blanket Additional Insured (Owners, Contractors Or Lessors) 1.Section C. Who Is An Insured is amended to include as an insured any person or organization whom you are required to name as an additional insured on this policy under a written contract or written agreement. The written contract or agreement must be: a.Currently in effect or becoming effective during the term of this policy; and b.Executed prior to the "bodily injury", "property damage", or "personal and advertising injury". 2.The insurance afforded to the additional insured is limited as follows: a.The person or organization is only an additional insured with respect to liability arising out of: (1)Real property, as described in a written contract or written agreement, you own, rent, lease, maintain or occupy; and (2)Caused in whole or in part by your ongoing operations performed for that insured. b.The Limit of Insurance applicable to the additional insured are those specified in the written contract or written agreement or the limits available under this policy, as stated in the Declara- tions, whichever are less. These limits are inclusive of and not in addition to the Limit of Insurance available under this policy. c.The insurance afforded to the additional insured does not apply to: (1)Liability arising out of the sole negligence of the additional insured; (2)"Bodily injury", "property damage", "personal and advertising injury", or defense coverage under the Supplementary Payments section of the policy arising out of an architect’s, en- gineer’s or surveyor’s rendering of or failure to render any professional services including: 13 4 1 9 4 of 2016 Liberty Mutual Insurance BP 79 96 09 16 Page 3 of 4Includes copyrighted material of Insurance Services Office, Inc.,with its permission. (a)The preparing or approving of maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifications; and (b)Supervisory, inspection, architectural or engineering activities. (3)Any "occurrence" that takes place after you cease to be a tenant in the premises described in the Declarations; or (4)Structural alterations, new construction or demolition operations performed by or for the person or organization designated in the Declarations. 3.Any coverage provided hereunder shall be excess over any other valid and collectible insurance avail- able to the additional insured whether primary, excess, contingent or on any other basis unless a contract specifically requires that this insurance be primary or you request that it apply on a primary basis. F. Newly Formed Or Acquired Organizations The following is added to Section C. Who Is An Insured: Any business entity acquired by you or incorporated or organized by you under the laws of any individual state of the United States of America over which you maintain majority ownership interest exceeding fifty percent. Such acquired or newly formed organization will qualify as a Named Insured if there is no similar insurance available to that entity. However: 1.Coverage under this provision is afforded only until the 180th day after the entity was acquired or incorporated or organized by you or the end of the policy period, whichever is earlier; 2.Section A.1. Business Liability does not apply to: a."Bodily injury" or "property damage" that occurred before the entity was acquired or incorporated or organized by you; and b."Personal and advertising injury" arising out of an offense committed before the entity was ac- quired or incorporated or organized by you. 3.Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations. G. Aggregate Limits The following is added to Paragraph D.4. Aggregate Limits Liability and Medical Expenses Limits Of Insurance: 1.The Aggregate Limits apply separately to each of the "locations" owned by or rented to you or temporarily occupied by you with the permission of the owner. 2.The Aggregate Limits also apply separately to each of your projects away from premises owned by or rented to you. For the purpose of this endorsement only, "location" means premises involving the same or connect- ing lots, or premises whose connection is interrupted only by a street, roadway, waterway or right- of-way of a railroad. H. Duties In The Event Of Occurrence, Offense, Claim Or Suit 1.Paragraph E.2.a. Duties In The Event Of Occurrence, Offense, Claim Or Suit Liability And Medical Expenses General Condition applies only when the "occurrence" is known to any insured listed in Paragraph C.1. Who Is An Insured or any "employee" authorized by you to give or receive notice of an "occurrence" or claim. 2.Paragraph E.2.b. Duties In The Event Of Occurrence, Offense, Claim Or Suit Liability And Medical Expenses General Condition will not be considered breached unless the breach occurs after such claim or "suit" is known to any insured listed under Paragraph C.1. Who Is An Insured or any "employee" authorized by you to give or receive notice of an "occurrence" or claim. 13 5 1 9 4 of 58 5 3 4 1 5 7 00 2 1 7 4 28 0 2016 Liberty Mutual Insurance BP 79 96 09 16 Page 4 of 4Includes copyrighted material of Insurance Services Office, Inc.,with its permission. I.Section F. Liability And Medical Expenses Definitions is modified as follows: 1.Paragraph F.3.is replaced by the following: 3."Bodily Injury" means bodily injury, sickness, disease, or incidental medical malpractice injury sustained by a person, and includes mental anguish resulting from any of these; and including death resulting from any of these at any time. 2.Paragraph F.9.is replaced by the following: 9."Insured contract" means: a.A contract for a lease of premises. However, that portion of the contract for a lease of prem- ises that indemnifies any person or organization for damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract"; b.A sidetrack agreement; c.Any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad; d.An obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; e.An elevator maintenance agreement; f.That part of any other contract or agreement pertaining to your business (including an indem- nification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization, provided the "bodily injury" or "property damage" is caused, in whole or in part, by you or by those acting on your behalf. However, such part of a contract or agreement shall only be considered an "insured contract" to the extent your assumption of the tort liability is permitted by law. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. Paragraph f.does not include that part of any contract or agreement: (1)That indemnifies a railroad for "bodily injury" or "property damage" arising out of con- struction or demolition operations, within 50 feet of any railroad property and affecting any railroad bridge or trestle, tracks, road-beds, tunnel, underpass or crossing; (2)That indemnifies an architect, engineer or surveyor for injury or damage arising out of: (a)Preparing, approving, or failing to prepare or approve, maps, shop drawings, opin- ions, reports, surveys, field orders, change orders or drawings and specifications; or (b)Giving directions or instructions, or failing to give them, if that is the primary cause of the injury or damage; or (3)Under which the insured, if an architect, engineer or surveyor, assumes liability for an injury or damage arising out of the insured’s rendering or failure to render professional services, including those listed in (2)above and supervisory, inspection, architectural or engineering activities. 3.Paragraph F.14.b. Personal And Advertising Injury is replaced by the following: b.Malicious prosecution or abuse of process; 11 1 2 of 58 5 3 4 1 5 7 00 2 5 7 4 28 0 CITY OF CARSON 701 E CARSON STREET CARSON CA 90745 POLICY NUMBER:BUSINESSOWNERS BP 04 97 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASEREAD IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGEFORM BP 04 97 01 06 ISO Properties, Inc., 2004 Page 1 of 1 SCHEDULE* Name Of Person Or Organization: Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section III - Common Policy Conditions is amended by the addition of the following: 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 organi- zation shown in the Schedule above. *Information required to complete this Schedule, if not shown above, will be shown in the Declarations.