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03-1104_UNITED CEREBRAL PALSY ASSOCIATION_License Agreement LICENSE AGREEMENT FOR USE OF PUBLIC PROPERTY This I icense Agreement (the "Agreement") is made this �y of 003, by and between the CITY OF SAN JUAN CAPISTRANO, a municipal corporation, hereinafter referred to as "Licensor", and the UNITED CEREBRAL PALSY ASSOCIATION OF ORANGE COUNTY, INC., hereinafter referred to as "Licensee". Licensor and Licensee mutually agree as follows: 1. License to Use Certain Public Property. Licensor hereby grants to Licensee a license right to use certain public property described as the EI Horno/El Camino Real Parking Lot ("Property"). The purpose of this license is to allow Licensee to park Licensee's Totmobile on the property and operate Licensee's early intervention program. Licensee shall not use the Property for any other purpose. 2. Hours of Operation. Licensee shall park the Totmobile on the Property every Friday between the hours of 8:30 a.m. and 1:30 p.m. 3. Term, This Agreement shall be for a period of two (2) years beginning on the date signed. Licensor reserves the right to terminate this License Agreement by giving Licensee thirty (30) days advance written notice of termination. This Agreement may be terminated without cause. Licensee shall have the same right to termination. 4. Insurance Requirements. a) Comprehensive General Liability. Consultants shall maintain in full force and effect comprehensive general liability coverage, including premises operations, products/completed operations, broad from property damage and blanket contractual liability in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any one occurrence/not limited to contractual period. b) Comprehensive Automobile Liability. Consultants shall maintain in full force and effect comprehensive automobile liability coverage, including owned, hired and non-owned vehicles in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any once occurrence/not limited to contractual period. C) Worker's Compensation. If Licensee employs employees to perform services under this Agreement, Consultant shall obtain and maintain, during the life of this Agreement, Worker's Compensation Employer's Liability Insurance in the statutory amount as required by the state law. These policies shall not terminate, nor shall they be canceled nor the coverage reduced until after a thirty (30) day written notice is given to the City. Prior to beginning work, Licensee shall provide to City certificates of insurance establishing that the required insurance coverages have been secured by Consultant. Consultant shall provide an endorsement to City establishing that City has been legally added as an additional insured to the insurance policies required under this Agreement. 5. Hold Harmless. Licensee shall defend, hold harmless and indemnify Licensor and all officers and employees of the Licensor from all costs and claims for damages to real or personal property or personal injury to any third party which may arise out of Licensee's use of the Property. 6. Assignment. Licensee shall not transfer, encumber, or assign this Agreement in whole or in part, whether voluntarily or involuntarily, nor sublet all or any part of this Agreement. 7. Non-Exclusive License. Licensor reserves the right to allow other parities to utilize the Property for any purpose which Licensor may so designate. Licensor shall reasonably cooperate with Licensee by providing advance written notice of other potential uses which Licensor may place upon the Property. 8. Notices. Any notices required to be given under this Agreement shall be sent to the following parties: Licensor: City of San Juan Capistrano Attn.: Public Works Director 32400 Paseo Adelanto San Juan Capistrano, CA 92675 Licensee: United Cerebral Palsy Association of Orange County 3010 West Harvard Street Santa Ana, CA 92704-3989 9. Entire Agreement. This Agreement contains the entire agreement of parties hereto with respect to the matters covered hereby, and no other previous agreement, statement or promise made by any party hereto which is not contained herein shall be binding or valid. IN WITNESS WHEREOF, Licensor and Licensee have caused this Agreement to be executed on the day and year first hereinabove written. CITY OF SAN JUAN CAPISTRANO By: John S. Mayor UNITE CEREBRAL PALSY ASSOC►A ON- ORANGE COUNTY By: ATTEST: M rgaret R. Monahan, City Clerk APPROVED AS TO FORM: 4 4-� John R. ShaV, City Attorney 0 0 CITY CLERK'S DEPARTMENT-ACTION REMINDER TO: *,1% t Af*Yst l7 FROM: Mitzi Ortiz, Deputy City Clerk DATE: October 3, 2005 SITUATION: At their meeting on November 4, 2003, the City Council of the City of San Juan Capistrano entered into a License Agreement with United Cerebral Palsy Association of Orange County for the use of EI Horno/EI Camino Real parking lot for the purpose of operating an Early Intervention Program. ACTION REQUESTED: Said agreement is for a period of two years and is due to expire on November 4, 2005. Please notify this office if agreement has been completed or will be extended. ` ACTION TO BE TAKEN: 064 J� a( fid�/- DATE WHEN NEXT ACTION (S) SHOULD BE TAKEN: A-114- SIGNATURE OF OFFICIAL TAKING ACTION: DATE SIGNED: 6 do ***FOR CITY CLERK'S DEPARTMENT USE ONLY*** Tickler Date: 10/03/05 Deadline Date: 11/04/05 (600.30/united cerebral palsy) - 1 • • 11/4/2003 AGENDA ITEM D 5 TO: Pamela Gibson, Interim City Manager FROM: Amy Amirani, Public Works Director SUBJECT: Consideration of a License Agreement with the United Cerebral Palsy Association of Orange County for Operation of an Early Intervention Program RECOMMENDATION: By motion, approve the License Agreement with the United Cerebral Palsy Association for the purpose of operating an early intervention program on City property at EI Horno and EI Camino Real parking lot, and authorize the Mayor to execute the Agreement. SITUATION: A. Summary and Recommendation In February 1999, the City entered into a license agreement with the United Cerebral Palsy Association of Orange County (UCPA/OC) to station its Totmobile in San Juan Capistrano for a term of two years. The Totmobile is a mobile operating station, which facilitates the early intervention program, specifically dealing with infants. The Totmobile was stationed at the parking lot at EI Horno and EI Camino Real and was in operation one day a week from 9:00 a.m. to 12:00 p.m. The Totmobile was removed from the site at the end of the two-year term, and due to a drop in enrollment, the agreement was not extended or renewed at that time. To fulfill a need in the community, the City has been asked by UCPA/OC to once again use the parking lot at EI Horno and EI Camino Real to set up their Totmobile. The hours of operation for the Totmobile would be on Wednesdays from 8:30 a.m. to 1:30 p.m. UCPA/OC is requesting that this license agreement be for a period of two years. Since the EI Horno and EI Camino Real parking lot is adjacent to the public library, City staff has informed the library administrator of the dates and times the Totmobile will be parked at the site. Although the Totmobile will be using approximately six parking spaces, the impact to library patrons and personnel will be insignificant. Staff recommends approval of this license agreement between the City of San Juan Capistrano and the United Cerebral Palsy Association of Orange County for a term of two years. FOR CITY COUNCIL AGENDA` Agenda Item November 4, 2003 Page 2 B. Background UCPA/OC realized that transportation was a critical barrier for children with cerebral palsy and other medical problems who needed to receive education and therapy services. Commuting time and the lack of a convenient public transportation system prevented many families from taking their infants and toddlers to "centralized" programs to obtain the help they need. The UCPA/OC developed the idea of taking the early intervention program into the community where disabled children and their families live. A fifth-wheel vehicle, referred to as the Totmobile, was created to provide a "classroom on wheels". The interior was modified to hold a computer-learning center and other high tech teaching and play equipment, as well as adaptive items used in physical, occupational, and speech therapy. In 1994, the Totmobile began making regular visits to communities in Orange County, including Anaheim, La Habra, Costa Mesa, and San Juan Capistrano. The Totmobile provides maximum flexibility to meet a variety of needs of children anywhere in Orange County. Hundreds of children have benefited from UCPA/OC's Early Intervention Program and have subsequently enjoyed improved intellectual and motor development. The quality of their lives has been significantly enhanced. COMMISSION/BOARD REVIEW AND RECOMMENDATIONS: Not applicable. FINANCIAL CONSIDERATIONS: Not applicable. NOTIFICATION: United Cerebral Palsy Association of Orange County Orange County Public Library ALTERNATE ACTIONS: 1. By motion, approve the License Agreement with the United Cerebral Palsy Association of Orange County for the purpose of operating an early intervention program on City property at EI Horno and EI Camino Real parking lot, and authorize the Mayor to execute the Agreement. 2. By motion, do not approve the License Agreement with the United Cerebral Palsy of Orange County. 1 Refer to staff for additional information. Agenda Item November 4, 2003 Page 3 RECOMMENDATION: By motion, approve the License Agreement with the United Cerebral Palsy Association Orange County for the purpose of operating an early intervention program on City property at EI Horno and EI Camino Real parking lot, and authorize the Mayor to execute the Agreement. Respectfully submitted, Prepared by Amy Amir&ni Kathleen Spnnger Public Works Director Management Analyst I AA:KS/mp Attachments: 1. License Agreement 2. Location Map LICENSE AGREEMENT FOR USE OF PUBLIC PROPERTY This License Agreement (the "Agreement") is made this _ day of , 2003, by and between the CITY OF SAN JUAN CAPISTRANO, a municipal corporation, hereinafter referred to as "Licensor", and the UNITED CEREBRAL PALSY ASSOCIATION OF ORANGE COUNTY, INC., hereinafter referred to as "Licensee". Licensor and Licensee mutually agree as follows: 1. License to Use Certain Public Property. Licensor hereby grants to Licensee a license right to use certain public property described as the EI Horno/EI Camino Real Parking Lot ("Property'). The purpose of this license is to allow Licensee to park Licensee's Totmobile on the property and operate Licensee's early intervention program. Licensee shall not use the Property for any other purpose. 2. Hours of Operation. Licensee shall park the Totmobile on the Property every Friday between the hours of 8:30 a.m. and 1:30 p.m. 3. Term. This Agreement shall be for a period of two (2) years beginning on the date signed. Licensor reserves the right to terminate this License Agreement by giving Licensee thirty (30) days advance written notice of termination. This Agreement may be terminated without cause. Licensee shall have the same right to termination. 4. Insurance Requirements. a) Comprehensive General Liability. Consultants shall maintain in full force and effect comprehensive general liability coverage, including premises operations, products/completed operations, broad from property damage and blanket contractual liability in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any one occurrence/not limited to contractual period. b) Comprehensive Automobile Liability. Consultants shall maintain in full force and effect comprehensive automobile liability coverage, ATTACHMENT 0 0 including owned, hired and non-owned vehicles in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any once occurrence/not limited to contractual period. C) Worker's Compensation. If Licensee employs employees to perform services under this Agreement, Consultant shall obtain and maintain, during the life of this Agreement, Worker's Compensation Employer's Liability Insurance in the statutory amount as required by the state law. These policies shall not terminate, nor shall they be canceled nor the coverage reduced until after a thirty (30) day written notice is given to the City. Prior to beginning work, Licensee shall provide to City certificates of insurance establishing that the required insurance coverages have been secured by Consultant. Consultant shall provide an endorsement to City establishing that City has been legally added as an additional insured to the insurance policies required under this Agreement. 5. Hold Harmless. Licensee shall defend, hold harmless and indemnify Licensor and all officers and employees of the Licensor from all costs and claims for damages to real or personal property or personal injury to any third party which may arise out of Licensee's use of the Property. 6. Assignment. Licensee shall not transfer, encumber, or assign this Agreement in whole or in part, whether voluntarily or involuntarily, nor sublet all or any part of this Agreement. 7. Non-Exclusive License. Licensor reserves the right to allow other parities to utilize the Property for any purpose which Licensor may so designate. Licensor shall reasonably cooperate with Licensee by providing advance written notice of other potential uses which Licensor may place upon the Property. 8. Notices. Any notices required to be given under this Agreement shall be sent to the following parties: Licensor: City of San Juan Capistrano Attn.: Public Works Director 32400 Paseo Adelanto San Juan Capistrano, CA 92675 Licensee: United Cerebral Palsy Association of Orange County 3010 West Harvard Street Santa Ana, CA 92704-3989 9. Entire Agreement. This Agreement contains the entire agreement of parties hereto with respect to the matters covered hereby, and no other previous agreement, statement or promise made by any party hereto which is not contained herein shall be binding or valid. IN WITNESS WHEREOF, Licensor and Licensee have caused this Agreement to be executed on the day and year first hereinabove written. CITY OF SAN JUAN CAPISTRANO By: John S. Gelff, Mayor UNITED CEREBRAL PALSY ASSOCiA I-ONO ORANGE COUNTY By: ATTEST: Margaret R. Monahan, City Clerk APPROVED AS TO FORM: 4 �k� John R. Shar, City Attorney i k Scale: 1" = 73 ' .� Parking Lot at EI Horno & f ' EI Camino Real ht CityGIS2 ' - Copyrigtt 0 2002,A11 fd¢hts Reserved The information ocntained herein is the proprietary property d the contdtxdars supplied under license and may rot be reproduced except as li censed by Cigtal Map Products ATTACHMENT OTHOLDER COPY SG STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSUPtANCE FU N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-01-2005 GROUP: POLICY NUMBER: 1419787-2005 CERTIFICATE ID: 19 CERTIFICATE EXPIRES: 07-01-2006 07-01-2005/07-01-2006 CITY OF SAN JUAN CAPISTRANO SG JOB: ALL OPERATIONS CITY CLERKS OFFICE ATTN: DAWN SCHANOERL 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer:named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer. We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extendoralter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of;insurance 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. X _ d , M4 AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. . EMPLOYER " LEGAL NAME UNITED CEREBRAL PALSY _ - . UNITED CEREBRAL PALSY ASSOC. OF O.0 ASSOCIATION OF D.C.J 230 COMMERCE STE ' 190 IRVINE CA 92602 tREV.3-031 - _ PRINTED: 08/17/2005 P0408 THIS DOCUMENT a BACKGROUND SCtF 1026t, r , Client#:9.0 CER3 ACORU. CERTIFICATE OF LIABILITY INSURANCE oiiui o Dmyr) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Commercial Support-Irvine ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SullivanCurtisMonroe40721187 RECEIVED HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2100 Main Street,Suite 350 Irvine,CA 926147no% INSURERS AFFORDING COVERAGE NAIC# INSURED g INSURERA: Philadelphia Indemnity Ins Company United Cerebral Palsy As Cl I Y CLERK INSURER B'. 230 Commerce,SI�tAe01JAN CAPISTRANO INSURER C: Irvine,CA 92602 INSURER O: INSURER E'. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 40131 TR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE M D DATE MIll A GENERAL UABIUTY PHPK128474 07!01105 07101106 EACH OCCURRENCE $1.000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $100,000 CLAIMS MADE O OCCUR MED EXP(Any one person) $5,000 PERSONAL S AOV INJURY $1.000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000000 POLICY 7JECT PRO LOC A AUTOMOBILE LIABILITY PHPK128174 07/01/05 07/01/06 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea acadent) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS 8001LV INJURY $ X NON-OWNED AUTOS (Per acadent) PROPERTY DAMAGE $ (Per acadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ A EXCESS/UMBRELLA LIABILITY PHUB048196 07/01/05 07/01/06 EACH OCCURRENCE $1000000 OCCUR X❑CLAIMS MADE AGGREGATE $1,000,000 DEDUCTIBLE $ X RETENTION $10000 $ WORKWCERS COMPENSATION AND STnTL'- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIIdEMBER EXCLUDED E.L.DISEASE-EA EMPLOYEE Y It yea,describe antler SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except for 10 days for non-payment of premium. * Supplemental Name er United Cerebral Palsy Assoc. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Ten Day Notice for Non-Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of San Juan Capistrano DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ran DAYS WRITTEN 32400 Paseo Adelanto NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL San Juan Capistrano,CA 92675 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUT GIRDED REPRESENTATIVE ACORD 25(2001108)1 of 3 #M8749 CSA 0 ACORD CORPORATIO 988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S(2007108) 2 of 3 #M8749 DESCRIPTIONS (Continued from Page 1) of Orange County,Inc. Certificate Holder is named as additional Insured per attached endorsement AMS 25.3(2001108) 3 of 3 #M8749 POLICY NUMBER: PHPK128174 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (If no entry apppears 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 operations or premises owned by or rented to you. CG 20 26 11 85 Client#: 97& UNITECER3 AC©RDr CERTIFIC E OF LIABILITY INS NCE x6;30/ °r '"" PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 949.250-7172 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SullivanCurtisMonroe#0721187 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2100 Main Street, Suite 350 Irvine, CA 92614 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Philadelphia Indemnity Ins Company United Cerebral Palsy Assoc. of Orange County, Inc. INSURER B: 230 Commerce, Suite 190 INSURER C: RE : Irvine,CA 92602 I INNSUSURER DR E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICYINSK AUDI EFFECTIVE POLICY EXPIRATION LTR INSR9TYPE OF INSURANCE POLICY NUMBER A MMIDDMI UMD3 A GENERAL LIABILITY PHPK086337 07/01/04 07/01/05 EACH OCCURRENCE 11000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RPREMISES(E.ENTED $100000 CLAIMS MADE O OCCUR MED EXP(Any aro person) $5,000 PERSONAL 6 ADV INJURY S1,000,000 GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY PRO- LOC A AUTOMOBILE LIABILITY PHPK086337 07/01/04 07/01/05 COMBINED SINGLE LIMIT ANY AUTO (Ea accident $1,000,OOO ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-01NED AUTOS (Per accident S PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S A EXCESS/UMBRELLA LIABILITY PHUB032665 07/01/04 07/01/05 EACH OCCURRENCE $1000000 _ OCCUR Ex—]CLAIMS MADE AGGREGATE S1 DOO 000 S DEDUCTIBLE $ X RETENTION $10000 $ WORKERS COMPENSATION AND WC STAN- OTH- ER EMPLOYERS'UABIUTY ANY PROPRIETOWPARTNEWEXEJU'rIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE i If yes,describe under SPECIALALPROVISIONS below E.L.DISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate Holder Is named as additional insured per attached endorsement CERTIFICATE HOLDER CANCELLATION Ton DBIV Notice for Non.paVMgnt of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of San Juan Capistrano DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL q0_ DAYsWRITTEN 32400 Paseo Adelanto NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOD0305 L San Juan Capistrano, CA 92675 IMPOSE NO OBLIGATION OR LUMILITY OF ANY KIND UPON THE INSURER,ITS AGE REPRESENTATIVES. ORIZED REPRESENTATIVE RNJ'^"r""w J ACORD 25(2001108) 1 of 2 #M7211 LMI 9 ACORD CORPORATION 1988 Adlik IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 254S(200'1108) 2 of 2 #M7211 POLICY NUMBER: PHPK086337 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (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 operations or premises owned by or rented to you. CG 20 26 11 85 UCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 COMM,ERCIAL Au . wl',OB�LE INSURANCE Insurer: Philadelphia Limits of Liability: Combined Single Limit,Bodily Injury&Property $1,000,000 Uninsured Motorist/Underinsured Motorist Bodily Injury $300,000 Medical Payments Not Covered Comprehensive Deductible $500 Collision Deductible $1,000 Rental Reimbursement Limited Non Owned Auto Liability Included Hired Auto Liability Included Hired Auto Physical Damage Not Covered Drive Other Car Coverage No Personal Injury Protection No Principal Exclusions: Wear&Tear Liability Assumed Under Any Contract Loss to Tape Decks or Other Sound Reproducing Equipment not Permanently Installed in a Covered Auto Pollution Care,Custody&Control Terms&Conditions: Composite Rate No Auditable No Vehicles Covered: 1994 Ford F350 P(U#5227 1994 Weekend Warrior#4472 Note: We recommend that you review the motor vehicle records(MVR)of all employed drivers on a periodic basis and of all potential drivers prior to allowing access to your vehicles. We can order these MVRs for you, however,we cannot release them to you unless you have received authorization to do so from the individual drivers. Therefore, we are assuming that when you ask for an MVR, you have obtained this authorization. We can provide you with a sample authorization and release form at your request. Coverages subject to the terms and conditions as defined in thepolicy `�I11_Iiv allCulti01olun F:\Wp\Clients-Comml\U\UCP of Omnge County\Prmposals\pr 07-1-04.dm SO POLICYHOLDER COPY STATE P.O. BOX 807. SAN FRANCISCO,CA 94142-0807 ICoMpNS UI°I ANC k FNS U N O CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-01-2004 GROUP: POLICY NUMBER: 1418787-2004 CERTIFICATE ID: 18 CERTIFICATE EXPIRES; 07-01-2005 07-01+2004/07-01-2005 CITY OF SAN JUAN CAPISTRANO SG JOB: ALL OPERATIONS CITY CLERKS OFFICE ATTN: DAWN SCHANDERL 32400 PASEO ADELA14TO SAN JUAN CAPISTRANO, CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon ao days' advance written notice to the employer. We will also give you ab days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. ipfwithstanding any reguirerpent, term, or condition of any contract or other document with respect to which this certificate of insurance 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. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER LEGAL NAME UNITED CEREBRAL PALSY UNITED CEREBRAL PALSY ASSOC. OF O.C. ASSOCIATION OF O.C. 230 COMMERCE STE 190 IRVINE CA 92602 a 08/17/2004 THIS DOCUMENT D BACKGROUND r 47TOUCP of Orange County July 23, 2004 Understanding Disabilities Creating Opportunities United Cerebral Palsy of Orange County City of San Juan Capistrano Attn: Cit Clerk's office 230 Commerce,Suite 190 y Irvine.CA 92602-1336 32400 Paseo Adelanto San Juan Capistrano, CA 92675 tat 714-200-2600 main fax 714-200-2640 program fax 714-200-2641 Ms, www ucpaoc.org Please find enclosed forms to meet your insurance requirements pputver@ucpaoc org listed on letter of June 8. Grant Dunning President Forms were not delivered sooner to your location because contract Oscar Garza was not final until after July 151. Vice President Geoff Coar If any other materials are needed, please contact me. Secretary/Treasurer Suzi Brown Past President Sincerely, Richard A.Cohn Kelly Dudley Jeffery Haydel �/ '��� v•� Gunnar Gooding Rene W.Henriksen Barbara Jones Douglas Ingram Director of Finance Gordon MacLean Jeffrey H.Reeves mom Scheel Jon Schisler Scott Swearingen Paul F.Pulver Executive Director A United Way Agency 10 Client#: 9 NITECER3 ACORD..' CERTIFICATE OF LIABILITY INSURANCE 0DATE 6/30/040nrvv) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 949-250-7172 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SullivanCurtisMonroe#0721187 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2100 Main Street, Suite 350 Irvine, CA 92614 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Philadelphia Indemnity Ins Company United Cerebral Palsy Assoc. INSURER B: of Orange County, Inc. INSURER C. 230 Commerce, Suite 190 INSURER D: Irvine, CA 92602 INSURER E. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE MFFECTII DATE EXPIRATION A GENERAL LIABILITY PHPK086337 07/01/04 07/01/05 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence) $100,000 CLAIMS MADE 5x] OCCUR MED EXP(Anyone person) $5,000 PERSONAL 8 ADV INJURY S1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2 000 000 POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY PHPK086337 07/01/04 07/01/05 COMBINED SINGLE LIMIT E1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY E X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY E X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE E (Peracadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ A EXCESSIUMBRELLAUABIUTY PHUB032665 07/01/04 07/01/05 EACH OCCURRENCE $1000000 OCCUR CLAIMS MADE AGGREGATE $1,000,000 S DEDUCTIBLE $ X RETENTION $10000 $ WORKERS COMPENSATION ANDWCSTATU- I OTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXLJU FIVE E.L.EACH ACCIDENT b OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If PES,dee Cnbe Under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder is named as additional insured per attached endorsement CERTIFICATE HOLDER CANCELLATION Ton DEI Notice for Non�PaVrrlent of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of San Juan Capistrano DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL AQ_ DAYSWRTITEN 32400 Paseo Adelanto NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL San Juan Capistrano, CA 92675 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AJITHORIZED REPRESENTATIVE 14ftT`�`�'At,nh, . ACORD 25(2001/08) 1 of 2 #M7211 LMI © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S(2001/08) 2 of 2 #M7211 POLICY NUMBER: PHPK086337 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (If noentry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section ll) 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 operations or premises owned by or rented to you. CG 20 26 11 85 dew, 32400 PASEO ADEIANTO v /, F� MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO,CA 92675 //j ILLS' SAM ALLEVATO (949)493-1171 r(✓/J,�/� m[o RvoAAIlo DIANE L.BATHGATE (949)493-1053 FAX [STAILISM 1961 WYATT HART v ww sanj uancapi.struno.org 1776 JOE SOTO • • DAVID M.SWERDLIN June 8, 2004 United Cerebral Palsy Assoc. of Orange County, Inc. 3010 West Harvard Street Santa Ana, CA 92704 RE: Compliance with Insurance Requirements — Use of EI Horno/EI Camino Real Parking The following insurance documents are due to expire: V, General Liability Certificate 07/01/2004 \ ✓ General Liability Endorsement Form naming the City of SdtS Juan Capistrano as additional insured. ✓ Automobile Liability Certificate 07/01/2004 /n/.. ✓ Workers Compensation Certificate 07/01/2004 ` Please submit upd ed documentation to the City of San Juan Capistrano, a ention City Clerk's office, 32 Paseo Adelanto, San Juan Capistrano, CA 92675 by the above 5cretary a . If ou have any questions, please contact me at (949) 443-6309. ara cc: Gena Schenkenberger, Secretary San Juan Capistrano: Preserving the Past to Enhance the Future • CERTIFICATE HOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NOVEMBER 25, 2003 GROUP: POLICY NUMBER: 1419787-2003 CERTIFICATE ID: 42 CERTIFICATE EXPIRES: 07-01-2004 07-01-2003/07-01-2004 CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92675 This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend,extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate of insurance 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. ?, / - A, 'A . AL AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1, 000, 000 PER OCCURRENCE ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER UNITED CEREBRAL PALSY ASSOC. OF O.C. 3010 W HARVARD ST SANTA ANA CA 92704 SCIF 10262E [EPF•UI: BO t Client#: %lTECER3 ACORD,. CERTIFICATE OF LIABILITY INSURANCE 11124/0,°"Y"' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 949-250-7172 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SullivanCUrtisMonroe HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2100 Main Street,Suite 350 Irvine, CA 92614 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Philadelphia Indemnity Ins Company United Cerebral Palsy Assoc. INSURER B: Twin Cities Fire Ins Co of Orange County Inc. INSURER C: 3010 West Harvard Street INSURER D: Sana Ana,CA 92704 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONIDDIYYI LIMITS A GENERAL LIABILITY PHPK053640 07/01/03 07/01/04 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES ,nno $100,000 CLAIMS MADE 5x]OCCUR MED EXP(Any one person) $5,000 A Professional PHPK053640 07/01/03 07/01/04 PERSONAL In ADV INJURY $1000000 Liab$1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2000000 JECT POLICY PRO LOC A AUTOMOBILE LIABILITY PHPK053640 07/01/03 07/01/04 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (p.s.c ulant) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ R AUTO ONLY: AGO $ A EXCESS/UMBRELLAUABILITY PHUB020317 07/01/03 07/01/04 EACH OCCURRENCE $1000000 OCCUR 7 CLAIMS MADE AGGREGATE $1,000,000 f DEDUCTIBLE $ X RETENTION $10000 f WORKERS COMPENSATION ANO WC STATU-I 0THJQRY LIMITS FIR - EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,descnbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ B OTHER OA1000338 07/01/03 07/01/04 Directors&Officers Liability-$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate Holder is named as additional insured per attached endorsement CERTIFICATE HOLDER CANCELLATION Ton DaX Notice for Non-Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of San Juan Capistrano DATE THEREOF,THE ISSUING INSURER WILL EN DEAVOR TO MAIL -In DAYS WRITTEN 32400 Paseo Adelanto NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL San Juan Capistrano,CA 92675 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. A THORIZEDE RESENTATIVE ACORD 25(2001108)1 of 2 #M5296 SKF o ACORD CORPORATION 1988 POLICY NUMBER: PHPK053640 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (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 operations or premises owned by or rented to you. CG 20 26 11 85 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2001108) 2 of 2 #M5296 Y{" MEMBERS OF THE CITY COUNCIL DIANETE JOHN ..GELFF MATT HART JOESOTO 32400 PASEO ADELANTO }//��L IIf1AIlAAil1 DAVID M.SWERDLIN SAN JUAN CAPISTRANO, CA 9267S • 0111DHR I 1961 (949) 493-1171 1776 (949) 493-1053 (FAX) INTERIM CIN MANAGER rvww.sanjuancapistrano.org PAMELAGIBSON December 2, 2003 Cerebral Palsy Association of Orange County, Inc. 3101 West Harvard Street Santa Ana, CA 92704 Dear Sir or Madam: A fully executed, original License Agreement for use of public property related to the EI Horno/EI Camino Real Parking lot is enclosed. Thank you for forwarding current evidence of insurance as required by the agreement. Please keep in mind that this documentation must be maintained current with our office, or all work under this agreement must stop and all payments for services rendered will be withheld, until these documents are brought current. You may proceed with the terms of this agreement in coordination with the Project Manager, Kathleen Springer, Management Analyst I, (949) 487-4306. Yours truly, , ^ Meg nah n, CMC City lerk enclosed: Agreement cc: Kathleen Springer, Management Analyst I Amy Amirani, Public Works Director San Juan Capistrano: Preserving the Past to Enhance the Future Nov-25-2003 06:55am From-SULLIVANCURTISMO ♦949-962-9762 4-550 FAIII/002 F-514 \�r RISK MANAGEMENT Su1livanCur sMonroe INSURANCE BROKERAGE 2100 MAIN STREET,SUI"E 350 IRVINE,CALIFORNIA 92614 TELEPHONE (949)251-7172 FACSIMILE (949)85.?-9762 CA LICENSE#0-,21187 IRVINE• PASi DENA HONOLULU• SEATTLE FACSIMILE To: Kathleen Springer Date: November 24, 2003 Firm: City of San Juan Capistrano Fax #: 949-493-3955 From: Sarah Froebe Re: Certificate of Insurance Pages: United Cerebral Palsy Assoc nafadin ov vJ MESSAGE: Original to follow in mail, Have a wonderful day! 1� 1 p D y This message is inrended for the use of the individual entity to which It Is addressed and may contain information that Ispnvileged, confidential and exempt frorn disclosure under applicable taw. If the reader of this atessage is nor the intended recipient, or the employee or agent responsiblefor delivering rhe message to the intended recipient,you are hereby notified that any disscmmation,distribution or copy ing ofthis communication is strictly prohibited. Ifyou have received this communication in error,please notify us immediately by telephone,<no return rhe original message to us or the address on this fax via the US Posral Service. Thank you. Nov-25-2003 0818am From-SULLIVANCURTISMON� +848-852-8782 It P,002/002 F-514 CERTIFICA OLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION I N 5 V R A N C e FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NOVEMBER 25, 2003 GROUP: POLICY NUMBER: 14 19187-2 003 CERTIFICATE IO: 42 CERTIFICATE EXPIRES: 07-01-2iO4 07-01-2003/07.01-2004 CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92675 This is to certify that we have issued a valid Worker's Compensation insurance policy In a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of Insurance is not an insurance policy and does not amend,extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate of insurance 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, Au HORIEEO REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000, 000 PER OCCURRENCE ENDORSEMENT 42065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-0I-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPI.OYER UNITED CEREBRAL PALSY ASSOC, OF O.C. 3010 W HARVARD ST SANTA ANA CA 92704 SCIF 10262E IEPF•Ul: 801 Nov-24-2003 02:41 pm From-SULLIVANCURTISNONO +946-852-9762 520 P.001/004 F-463 RISK MANAGEMENT SullivanCurtisMonroe INSURANCE BROKERAGE 2100 MAIN STREET, SUITE 350 IRVINE, CALIFORNIA 12614 TELEPHONE (949)25C-7172 FACSIMILE (949)85:-9762 CA LICENSE #07. ?1187 IRVINE• PASADENA HONOLULU • SEi TTLE FACSIMILE To: Kathleen Springer Date: November 24, 2003 Firm: City of San Juan Capistrano Fax#: 949-493-3955 From: Sarah Froebe _ Re: Cerrificate of Insurance Pages: (including co r) United Cerebral Palsy Assoc MESSAGE: Original to follow in mail. Have a wonderful day! This message is imended for the use of the individual entity to which it is addressed and may contain information that is privileged, :onJidunilal and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient,or the employee o-agent responvible for delivering(lie message to the intended recipient,you are hereby notyled that any dissemination,distribution or coping of this communication is strictly prohibited, lfyou have received this communication In error,please notify us immediately by telephone, and return the original message to us at the address on ids fan via the US Postal Servme. Thank you Nov-24-2003 02,41pm From-SULLIVANCURTISE +849-852-8762 T-520 P 002/004 F-483 Clle td;970 UNIT 3 ACORD.. CERTIFICATE OF LIABILITY INSURANCE 11/21/0301 PRODUCV THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMF.TION 949-250-7172 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT E HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTENT OR SullivanCurtisMonroo ALTER THE COVERAGE AFFORDED BY THE POLICIES BE.LOW. 2100 Main Street,Suite 350 Irvine,CA 92614 INSURERS AFFORDING COVERAGE NIJC B INSURED INSURERA. Philadelphia Indemnity Ins Company United Cerebral Palsy Assoc. INSURER B: TWIn Cities Fire Ins Co of Orange County Inc. INSURER C: 3010 West Harvard Straat INSURER o: Sena Ana, CA 92704 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHST ENDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED C R MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, VA TYPE Of INSURANCE POLICY NUMBER MATFI MJD , POLICY L"T. I ON LIMITS A GONERALLIA IL1YY PHFIK053640 07101103 07/01/04 EACH OCCURRENCE 51 01000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED E10D DDD CLAIMS MADE a OCCUR MED EMP Any*no 08110o !$0110 A Professional PHPK053040 07/01103 07/91104 PERSONAL Y AOV INJURY 110-I0000 L.ieb5100,000 GENERAL AGGREGATE 520-10000 GEM%AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 62010000 POLICY r7 PRD• LOC A AUTOMOBILE LIABILITY PHPK053640 07/01103 07101/04 COMBINED SINGLE LIMIT a1,D)OrDDD ANYAVTO IW PcciaenU ALL OWNED AUTOS BODILY INJURY ! X /OHEOULEO AUTOS IPd,Parcory X HIRED AUTOS BODILY INJURY S X NON-OWNED AUTOS (Par eamenU PROPERTY DAMAGE S (PIT FGiCen(I GARAGE LIABILITY AUTO ONLY.EA ACCIDENT E ANYAUTO OTHER THAN EAACC S AUTO ONLY: AGG ! A EXCESSIUMBRIII LIABILITY PHUB020317 07101/03 07/01104 EACH OCCURRENCE a10D0000 OCCUR 7CWMS MADE AGGREGATE 11CDD000 a DEDUCTIBLE ! X RETENTION s 10000 a we STATU. oTH- W ORNERS COMPENSATION AND EMPLOYER'LIABILITY E.NEWE L.EACN ACCIDENT ! OFFICEONMEMBER EXCL DE09 ECU11VE E.L.DISEASE•EA EMPLOYEE E IIX61,dewty Under SGECIAIPROVISIONS NI" E.L.DISEASE POLICY LIMIT E g oTHeA OA1000336 07/01103 07101104 Directors&Officers Liability-$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder Is named as additional Insured per attached endorsement CERTIFICATE HOLDER CANCELLATION Tan Day Notice for Non-Payment aL SNOULO ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF 4 THE EXPIRATION City of San Juan Capistrano DATE THBREOF,THE ISSUING INSURER WILL ENOEAVORTOMAR. _3D,. DAYSWRITTEN 32400 Pasco Adelanto NOTICE TO THE CeRTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO BO SHALL San Juan Capistrano, CA 92675 ,MPOSS NO OBLIGATION OR LIABILITY OF ANY RIND UPON THE INSURER,I b AGENTS OR REPAESENTATVEB. .`r,THORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #M5296 uk* t4ug4wk4� SKF 0 ACORD COF PORATION 1988 Nov-24-2003 02:41pm from-SULOVANCURTI*E +848-852-8762 • T-520 P 003/004 F-483 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed, A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25.5(20071DB) 2 of 2 OM5296 Nov-24-2003 02:41 Pm From-SULLIVANCURTISMO +848-852-8762 •T-520 P 004/004 F-463 POLICY NUMBER: PHPK053640 COMMERCIAL GENERAL LIABILfrY 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 Person or Organization: Cicy of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (If no entry apppears above, information required to complete this endorsement will be shown in the Declar ttions as applicable to this endorsement.) the Schedule, but INSURED with respon ect to Viis biamended arito sing lout of your operas an tions the orprem premises rson or ownedtion by or shown in rented to you. CG 20 26 11 85 FROG • (FRI)NOV 14 2003 1 /ST. 15 :23/No. 6800576009 P I 230 Commerce, Ste. 190 O Irvine, CA 92602-1336 UCP Phone: (714) 200-2635 arnng,C'.1Wy FAX: (714) 200-2640 oi..nnirin., Email: bjonesOucpaoc.org Cnnnnq Oppnrtunrties FAX TRANSMITTAL SHEET DATE: 10-17-03 TO: Kathleen Springer FAX: 1-949-493-3955 FROM: Barbara Jones, Director of Finance SUBJECT: Endorsement agreement Worker's Comp Insurance Total of Cover & Following Pages: 2 MESSAGE: Kathleen please find worker's comp ensorsement attached. Thank you! Barbara hones United Cerebral Palsy of OC 4411Q, (�6 wa Cao, - N FROM (FRO NOV 14 2003 15ST, 15 :23/No6800576009 P 2 TERNS F PARTICIPATION IN A DESIG ED AEP 62 PREFERRED PROVIDER FACILITY 1419787-03 STATE RENEWAL COMrsNsAT10N SG I N S U RA N C■ 0-33-29-67 FU NSD ENDORSEMENT AGREEMENT PAGE 1 HOME OFFISAN FRANCISCO EFFECTIVE JULY 1, 2003 AT 12.01 A.N. ALL EFFECTIVE DATES ARE VVV AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME RECE��ED UNITED CEREBRAL PALSYN��� ASSOCIATION OP O.C. AUG 0 1 "L tt 3010 W HARVARD ST '4j9J SANTA ANA, CA 92704 ANY CONTRADICTION BETWEEN E POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY TH ENDORSEMENT. !1/ IT IS AGREED THAT TH POLICYHOLDER SHALL REFER ALL WORK 4a1 RELATED INJURIES OR ISEASE i0 AN AGREED DESIGNATED VV v PREFERRED PROVIDE FACILITY AT THE TIME OF A WORK RELATED INJURY OR UFON OWLEDGE OF A WORK RELATED INJURY OR DISEASE. uw�` IT IS FUR R AGREED THAT PARTICIPATION IN THIS PROGRAM IS VOLUNT Y AND IS EFFECTIVE FOR THIS POLICY PERIOD ONLY. RENEWAL F THIS PROGRAM IS OPTIONAL FOR THE POLICYHOLDER V ` AND TH INSURER AND MAY BE DEPENDENT UPON POLICYHOLDER COOP ATION IN THE REFERRAL OF INJURED WORKERS TO THE DES NATED PREFERRED PROVIDER. IT MAY ALSO BE DEPENDENT UP N POLICYHOLDER COOPERATION IN EARLY RETURN TO WORK D MODIFIED WORK PROGRAMS. IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO NAY AFFECTS THE RIGHT OF AN INJURED WORKER TO PREDESIGNATE A PHYSICIAN OR TO SELECT HIS OR HER OWN PHYSICIAN 30 DAYS AFTER THE DATE OF INJURY. IT IS FURTHER AGREED THAT ANY PREMIUM DISCOUNT GIVEN FOR PARTICIPATION IN THIS PROGRAM WILL. BE RESCtNDED_IF YOU ARE NO LONGER ELIGIBLE FOR PARTICIPATION, NOTHING IN THIS ENDORSEMENT CONTAINED $HALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JULY 23 , 2003 2430 AUTHORIZED REPRESENTATIVE PRESIDENT MEMBERS OF THE CITY COUNCIL DIANE TE JOHN 5..GELFF GELFF WYATT HART JOESOTO 32400 PASEO ADEL.ANTO III",811111 DAVID M.SWERDLIN SAN JUAN CAPISTRANO, CA 92675 ISUIIISNU 1961 (949) 493-1171 1776 (949) 493-1053 (FAX) INTERIM CITY MANAGER 1vuvrv.sonjuancapistran o.org PAMELAGIBSON November 5, 2003 NOTIFICATION OF ACTION BY THE CITY COUNCIL OF SAN JUAN CAPISTRANO On November 4, 2003 the City Council of San Juan Capistrano met regarding: "Consideration of a License Agreement with the United Cerebral Palsy Association of Orange County for Operation of an Early Intervention Program" Item No. D5 The following action was taken at the meeting: License agreement with United Cerebral Palsy Association of Orange County for operation of an early intervention program on City property at EI Horno and EI Camino Real parking lot approved; and the Mayor authorized to execute the agreement. The following documents are in the process of being executed: License agreement If you have any questions regarding this action, please contact Kathleen Springer, Management Analyst I at 487-4306 for more detailed information. Thank you, / V � Megdlerk an, CMC City Cc: United Cerebral Palsy Association of Orange County; Orange County Public Library; Amy Amirani, Public Works Director; Kathleen Springer, Management Analyst I San Juan Capistrano: Preserving the Past to Enhance the Future • Joe* • h!i MEMBERS OF THE CITY COUNCIL / DIANE L.BATHGATE GELFF JOHN S.GELFF MATT HART JOES111111111111 DAVID MM.SWEROLIN 32400 PASEO ADELANTO /��p 1 � SAN JUAN CAPISTRANO,CA 92675 ✓y M. (949) 493-1171 Ell"Om, ` 1961 (949) 493-1053 (FAX) 1776 INTERIM CITY MANAGER 1V 1V 1V SRpf i(QIiCQplSIYQHO.OY$ PAMELA GIBSON NOTIFICATION OF MEETING OF POTENTIAL INTEREST OF THE SAN JUAN CAPISTRANO CITY COUNCIL The City Council of San Juan Capistrano will meet at 7:00 p.m. on November 4, 2003 in the City Council Chamber in City Hall, to consider: "Consideration of a License Agreement with the United Cerebral Palsy Association of Orange County for Operation of an Early Intervention Program" — Item No. D5 If you have specific thoughts or concerns regarding this item, you are encouraged to participate in this decision making process. You can communicate with the City Council through correspondence addressed to the Council and/or by attending the meeting and speaking to the Council during the public meeting. Correspondence related to this item must be received at City Hall by 5:00 p.m. on Monday, November 3, 2003 to allow time for the Council to consider its content. If you would like to speak at the meeting, please complete a blue 'Request to Speak" form found inside the entrance to the Council Chamber. This form is turned in at the staff table, just in front of the Council dais. You will be called to speak by the Mayor when the item is considered. You have received this notice at the request of the City staff member Kathleen Springer, Management Analyst I. You may contact that staff member at (949) 487-4306 with any questions. The agenda, including agenda reports, is available to you on our web site: www.sanivancaoistrano.oro. If you would like to subscribe to receive a notice when agendas are posted to the web site, please make that request by sending an e-mail to: cou ncilcou ncil-agendas�sanivancapistano.org. Meg Monahan, CMC City Clerk cc: United Cerebral Palsy Association of Orange County; Orange County Public Library; Amy Amirani, Public Works Director; Kathleen Springer, Management Analyst I Received staff report San Juan Capistrano: Preserving the Past to Enhance the Future MEMBERS OF THE CITY COUNCIL DIANE L.SATHGATE J. JOHN S.GELFF y� MATT ART JOESOT OE SOTO 32400 FASEO ADELANTO ���{J� IA[111i111U DAVID M.SWERDLIN SAN JUAN CAPISTRANO, CA 92675 ',3,111ISA11 1 (BS� (949) 493-1171 1776 (949) 493-1053 (FAX) INTERIM CITY MANAGER IV1FID sanjuanCapistrana.Org PAMELAGIBSON ItQ November 6, 2003 United Cerebral Palsy Association of Orange County, Inc. 3101 West Harvard Street Santa Ana, CA 92704 Re: AgWiement for Use of Public Property: EI Horno/EI Camino Real Parking Lot Dear Sir or Madam: A License Agreement related to parking the United Cerebral Palsy Association of Orange County's Totmobile on the noted property and operating an early intervention program is in the process of being executed and will be issued upon receipt of required documentation related to contract terms under Section 4. Insurance. Insurance evidence may be faxed to: ATTENTION CITY CLERK (949) 493-1053, followed by original signed documents. Enclosed is a copy of the agreement terms for your reference in supplying this documentation. If you have questions specific to the contact, please contact the project manager, Kathleen Springer, Management Analyst I, (949) 487-4306. Please call the City Clerk's office at (949) 443-6308 if you have questions regarding the forms of insurance needed. Thank you, M 4Moahan, CMC C y cc: Kathleen Springer, Management Analyst I Amy Amirani, Public Works Director San Juan Capistrano: Preserving the Past to Enhance the Future LICENSE AGREEMENT FOR USE OF PUBLIC PROPERTY hn� )hThis Ljcense Agreement (the "Agreement") is made this �ay of (. ^,-2003, by and between the CITY OF SAN JUAN CAPISTRANO, a municipal corporation, hereinafter referred to as "Licensor", and the UNITED CEREBRAL PALSY ASSOCIATION OF ORANGE COUNTY, INC., hereinafter referred to as "Licensee". Licensor and Licensee mutually agree as follows: 1. License to Use Certain Public Property. Licensor hereby grants to Licensee a license right to use certain public property described as the EI Horno/EI Camino Real Parking Lot ("Property'). The purpose of this license is to allow Licensee to park Licensee's Totmobile on the property and operate Licensee's early intervention program. Licensee shall not use the Property for any other purpose. 2. Hours of Operation. Licensee shall park the Totmobile on the Property every Friday between the hours of 8:30 a.m. and 1:30 p.m. 3. Term. This Agreement shall be for a period of two (2) years beginning on the date signed. Licensor reserves the right to terminate this License Agreement by giving Licensee thirty (30) days advance written notice of termination. This Agreement may be terminated without cause. Licensee shall have the same right to termination. 4. Insurance Requirements. a) Comprehensive General Liability. Consultants shall maintain in full force and effect comprehensive general liability coverage, including premises operations, products/completed operations, broad from property damage and blanket contractual liability in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any one occurrence/not limited to contractual period. b) Comprehensive Automobile Liability. Consultants shall maintain in full force and effect comprehensive automobile liability coverage, including owned, hired and non-owned vehicles in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period and, $1,000,000 injury to more than one person/any once occurrence/not limited to contractual period. C) Worker's Compensation. If Licensee employs employees to perform services under this Agreement, Consultant shall obtain and maintain, during the life of this Agreement, Worker's Compensation Employer's Liability Insurance in the statutory amount as required by the state law. These policies shall not terminate, nor shall they be canceled nor the coverage reduced until after a thirty (30) day written notice is given to the City. Prior to beginning work, Licensee shall provide to City certificates of insurance establishing that the required insurance coverages have been secured by Consultant. Consultant shall provide an endorsement to City establishing that City has been legally added as an additional insured to the insurance policies required under this Agreement. 5. Hold Harmless. Licensee shall defend, hold harmless and indemnify Licensor and all officers and employees of the Licensor from all costs and claims for damages to real or personal property or personal injury to any third party which may arise out of Licensee's use of the Property. 6. Assignment. Licensee shall not transfer, encumber, or assign this Agreement in whole or in part, whether voluntarily or involuntarily, nor sublet all or any part of this Agreement. 7. Non-Exclusive License. Licensor reserves the right to allow other parities to utilize the Property for any purpose which Licensor may so designate. Licensor shall reasonably cooperate with Licensee by providing advance written notice of other potential uses which Licensor may place upon the Property. 8. Notices. Any notices required to be given under this Agreement shall be sent to the following parties: Licensor: City of San Juan Capistrano Attn.: Public Works Director 32400 Paseo Adelanto San Juan Capistrano, CA 92675