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11-0418_3M, INC._Transmittal from 3M 3M Roadway Maintenance Services April 18, 2011 ;Fill Thomas Senior Management Analyst City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, California 92675 RE: 3M Personal Services Agreements Dear Ms. Thomas: I have enclosed two original, executed Personal Services Agreements as requested. Additionally, two signed, original Software License Agreements and 3M's Certificate of Insurance are enclosed. Upon execution, please forward an original Personal Services Agreement and Software License Agreement for our records. Please send to my attention. 3M Company certifies that it is compliant with Immigration Reform & Control Act of 1986 (IBCA), Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA), and INA Section 274 - Unlawful Employment of Aliens and is registered with E-Verify. 3M's registration number for E-Verify is 82942. We look forward to working with you on this project. Should you have any questions or require additional information,please feel free to contact me. Regards, John P. Benz Contract Manager 3M Traffic Safety Systems Division 3M Center Building 0235-3A-09 St. Paul, Minnesota 55144-1000 (651) 733-9487 jpbcg?z �mn�i .coni Enclosures 164_ CERTIFICATE OF LIABILITY INSURANCE Page z of 1 04/12/2' ) - 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(les)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 confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willia of Minnesota, Inc. NAME ---_, -.. . 26 Century Blvd. PHONETi ..877-945-737.8.. FAX(AIC 888-467-,2378 P. 0. Sox 305191 1 E-MAIL Naskaville, TN 37230-5191 DRESS:_ certificates@willis.com_ _ _,.!NSURER(S)AFFORDINGCOVERAGE �....__._._,....,-..__ ....._._.---_�_._........_...� INSURERA:Old Republic Insurance Company 24147-001 INSURED 314 INSURER R Company ._ 3M Insu>:aace Department: INSURERC: )21dg 224-55N €NSURERD 5t. Paul, MN 55144 INSIiRERE: INSURER F: - COVERAGES CERTIFICATE NUMBER:1582.1951 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 WOCH THIS CERTIFICATE. MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLIO€ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF€NSURANCE aW SUB POLICY NUMBER POLtCYEFF POLICYEXP` LIMITS A GENERALLIABILITY Y MWZY 59131 13/1/2011 13/1/2014 EACHOCCURRENCE X COMMERC(ALGENEFRALLIASILfTY i PREM'>ETO aoccUM PREPA£SES Ea oecurEnca7,_..V.._$._. 1,0 Q 0,0O 0__.. CLAIMS-MADE l OCCUR s VIED EXP(Anyone person $ W_.L- . .1Q,000 i PERSONAL&ADV INJURY- _ 5, OO_ Q 00_ ,,,,- GENEAAGGREGATE 5,00 .OO QO - GEN'LAGGREGATELIMIT APPLIES PER: Jl PRODUCTS-COMPIOPAGG '$ 5,000.000 POLICY r7 PRO- n LOC A AUTOMOBILE=LIA61LiTY MWTB 21146 3/1/2013 3/1/2014 COMBIIED 6�1 €NGLELIMIT $ 21000,OQO f X ANY AUTO BOOILYWJURY(Perperson} 15 j H ALOVNEO �m1L;D AUTOS AUTO$ BOOILYINJURYIPeraccidenf ) Is HIREDAUTOS NON-OWNEDf € - PRORPETYDANIAGfr AUTOS 1! _ , {PeraccTY) �S 1 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAWS-MAD)_ AGGREGATE $ DED I RETENTION A WORKERS COMPENSATIONMWC11Fi992 00 '3/1/2011 3/1/2Q12 rX - H AND Et'vIPLOYERS'LIABILITY ` 3 THEY„€-1ML S ANY PROPRIETORIPARTNERIEXECUTIVE OFFECERNEviBEREmXCLUDED, NIA EL.EACNACCIDENT $ 2,Q00,000 ( lMandatoryinNH) _. EA EMPLOYEE $ 2,000,000..�W ff yes,desonbe under - ----- DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POUCYLIMIT S 2,000,000 IIL DESCMP'I ION OF OPERATIONS I LOCATIONS I VEHICLES{At£ach Acord 191,Additonal Remarks Schedule,if snore space is required) Regarding "General Liability” only, 3M Company hereby grants Additional insured status to City of San Juan Capistrano, limited to the conditions and terms of the "Personal Services Agreement" dated 5/3/2011, and limited to the operations of 3M Company. This Certificate of Liability is valid from 5/3/2011 to 12/31/2011. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POL€CIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL, BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 Coll:3326531 Tpl:1225264 Cert: 5 22951 ©1988- 01 0 ACORD COR PO RATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD