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Home My WebLink AboutItem No. 05 Independent CA for Instruction - Early LearnersText File City of Lake Elsinore 130 South Main Street Lake Elsinore, CA 92530 www.lake-elsinore.org File Number: ID# 16-371 Agenda Date: 9/13/2016 Status: Consent AgendaVersion: 1 File Type: AgreementIn Control: City Council Agenda Number: 5) Page 1 City of Lake Elsinore Printed on 9/8/2016 Page 1 of 1 REPORT TO CITY COUNCIL To:Honorable Mayor and Members of the City Council From:Grant Yates, City Manager Prepared by: Audrey Young, Management Analyst Date:September 13, 2016 Subject:Independent Contractor Agreement for Instruction – Early Learners Recommendation It is recommended that the City Council approve the Independent Contractor Agreement for Instruction – Early Learners in amount not to exceed $60,000 as approved by the City Attorney. Background The City of Lake Elsinore contracts with private instructors to perform recreational instruction at City owned facilities such as the Lake Community Center and Lake Elsinore Senior Center. The City of Lake Elsinore collects all of the registration fees for the classes through Rec1, a software program. Upon the City’s receipt of invoice, the City then pays each of the contract instructors 75 percent of the participation Registration Fees collected. The City retains 25 percent of the fees for facility maintenance and staffing costs. Discussion Early Learners is an existing business providing pre-school and ballet dance instruction at the Lake Community Center. Due to Early Learner’s popularity last year, the two instructors exceeded the City Manager’s signing authority threshold of $30,000. We anticipate that they will continue to maintain and potentially grow in popularity. Thus we anticipate Early Learners to exceed the City Manager’s signing authority threshold this year as well. As you may find attached in Exhibit A, Independent Contractor Agreement for Instruction – Early Learners is not to exceed $60,000. Fiscal Impact Since the City collects the Registration Fees and then pays the Instructor their 75 percent dues, the expenses are countered with the appropriate revenue stream and therefore, no fiscal impact is anticipated. Exhibits A – Agreement CITY OF LAKE ELSINORE INDEPENDENT CONTRACTOR AGREEMENT FOR INSTRUCTION THIS jNp -PENDEAIT CONTRACTOR AGREEMENT FOR INSTRUCTORS ("Agreement") is made and entered into o (,i j 20 an between the CITY OF LAKE ELSINORE, hereinafter the "CITY," and V hereinafter the "CONTRACTOR." 1. Purpose. The CITY hereby engages CONTRACTOR for purposes of providing instruction in skillful and competent manner, and shall abide by all laws in doing so. CONTRACTOR shall perform such other duties as are customarily performed by one holding such position in other same or similar businesses or enterprises as that engaged in by CITY and shall maintain instruction area in a clean, safe and orderly manner. 2. Contractor's Status. CONTRACTOR is an independent contractor and is solely responsible for his or her own actions or omissions. CONTRACTOR is not City's employee for any purpose. Any additional personnel performing the services under this Agreement on behalf of CONTRACTOR shall also not be employees of the CITY and shall at all times be under Contractor's direction and control. CONTRACTOR shall pay all wages, salaries and other amounts due such personnel in connection with their performance of this Agreement and as required by law. r 3. Term. The term of this Agreement shall begin and end June 30, 20.7 4. C011ectipn of Fees. Registration fees shall a coli cted by the CITY through set registration procedures implemented by designated CITY staff. The CONTRACTOR is not authorized to collect registration fees. Following the collection of registration fees, the CITY shall confirm the number of participants enrolled. The CONTRACTOR will be compensated only for participants who have paid. 5. ,C9mpensatlon. In consideration of th yq��rj. ormance of the instruction and/or services provided herein, the CONTRACTOR shall recelve %) of the participation registration fees collected for Instruction and/or services Identified in Section 1 above, exclusive of any facility entrance, pool use, field/court night lights, insurance fees and/or publicity fees where charged. Compensation to be paid to the Contractor shall not exceed $60,000 without prior additional written authorization from the City. It is also understood that all taxes and/or other withholdings are the CONTRACTOR'S responsibility. 6. Payment. The compensation provided in Section 5 shall be paid: i Upon satisfactory completion of instruction and/or services and receipt of an invoice within 45 days by CONTRACTOR submitted to the Community Services Department in the format specified by the Department, net 45 days; or — At the following designated intervals: and receipt of an invoice by CONTRACTOR submitted to the Community Services Department in the format specified by the Department, net 45 days. 7. B siness License Insurance and LiveScan. CONTRACTOR and any subcontractor agrees to obtain and follow all business license requirements as required by the Lake Elsinore Municipal Code, Chapter 5.08. All business license requirements must be met prior to contract approval. CONTRACTOR and any subcontractor agrees to obtain all insurance required and present valid insurance certificates In accordance with the attached Terms and Conditions. CONTRACTOR, its employees, agents, consultants, contractors and volunteers agrees to perform and provide proof of LiveScan. 8. Terms and Conditions. This Agreement includes the terms and conditions as printed and set forth on the following page, which terms and conditions are incorporated herein by reference; and the CONTRACTOR, by executing this Agreement, agrees to comply with such terms and conditions. CITY OF LAKE ELSINORE Dated: 2016 By:. Grant Yates, City Manager ATTEST: Susan M. Domen, MMC, City Clerk CONTR TOR..A4 If AVn J Dated: 2016 By: Print Name: Title: �r Business Name: Business License Number: v Class(es): r ! tr e 3 L Address:s Email Address. ' ■ Q �~ Phone Numbe Distribution as follows: White – P & R Admin Canary – Instructor Pink –Community Center TERMS AND CONDITIONS 1- EQUIPMENT AND LABOR: The Contractor shall furnish all lools, equipment, apparatus, supplies and materials unless otherwise mutually agreed by City. Contractor assumes all risk of loss, damage or harm to such equipment or materials arising in connection with this Agreement The Contractor shall perform the services under this Agreement in a skillful and competent manner and shall abide by all laws in doing so. 2. SUBCONTRACTORS: In the event a contractor will not be able to teach class due to illness, etc the Contractor will implement the following procedure: a. Contractor will procure a substitute contractor equally or better qualified and acceptable to Iha Clly to Instruct class at the prescribed lime and place. Subcon(raclora must meet the criminal background screening and fingerprinting requirements according to Cel Public Resources Code Section 5164, b. Contractor will notify assigned designated staff regarding the substitute's name, qualifications, address and phone. Payment for subcontractors shall be responsibility of (he Contractor. C, If a substitute cannot be procured, the class will be canceled and a make up class added to the end of the session. The conlraclorwill be responsible for nolifying the students of the cancellation. d Contractor is responsible for ensuring subcontractors must meet all of the criteria stipulated in these Terns and Conditions, including but not limited to, maintaining a valid City of Lake Elsinore Business License, providing valid certificates of insurance in accordance with City policies, and providing proof of LiveScan. 3, SUPERVISION: Contractor agrees to establish appropriate rules for conducting the class and to assume responsibility for student discipline to ensure adequate protection of students and facility. 4 FACILITY. The City shall be responsible for providing a suitable facility for the conduct of the class, unless otherwise noted under "Special Arrangements". Contractor shall pay City for any and all costs associated with using the facility. Contractor agrees to assume full responsibility for selling up any facility for instruction and for cleaning and/or restoring the facility to its usual condition following each class session. 5 ACCESS TO FACILITY: City representatives shall at all limes have access to facility, whenever class is in progress to monitor programs for quality. 6, CONDUCT: Contractor understands that the City is a public entity under the laws of the State of California, and that the City's purpose in engaging Contractor is to provide its residents wllh racraellonal activities in a mannor that will frust r4 sense of cornmunhy, security, fun and fair play. Conlrodor agrees to conducl hinlselffherself in a manner that will further Iheso goals. Contractor furlicor acknowledges that failure to do so will result in immediate termination of this Agreement, 7 COORDINATION OF WORK: The Contractor agrees to coordinate with the City spodli pme[a) and date[*) In ordorto avoid eoril l of use. It is agreed that the resolution of any conflict is of the solo dlscrellon of *7 City Manager of hialel' designee. Conlroclor agrees towork Will assigned City ataff to mainWri accurmla enrollment records 6 RULES: Contractor agrees to obey all rules and regulations of the City of Lake Elsinore and any directives and memoranda issued by the Department's Director. 9. LIVESCAN: Contractor, its employees, agents, consultants, contractors and volunleens inusl ocmply with 4ngorprinling roqulrements, Public Resource& Code, Section 5164, by prasenling proof of LiveScan to the City, prior to commencing work with minors. 10. HOLD HARMLESS AND INDEMNIFICATION. The Contractor shall defend, indemnify, and hold harmless the City, its offidals; officers, apanls, employees and volunteers free and harmless from any and all claims, demands, causes of action, cosi$, expemiea. Ilabilily, loss, damage or injury, in law or oqully to properly at persons, Including %wangful dee0r, In any manner arfsirlg our of our tacidurl to any ppmgad sots, omissions or willful misconduet of Conrracivr. Its omployaos, agonts, consultants, odillractors end voklrileers arising oul of or in connection with the purformance of the sarvices In this Agroamenl, including without Ilurtation the pa ymonl of ail consequential damages and apameys' fees and other related costs and expenses. Contractor shall pay and satisfy any judgment, sward or doornn that maybe rendered against City or its officials, officers, employees, agents, or volunteers, in any such suit, action or other legal proceeding. Conlrom er shall reimburse City and its officials, officers, employees, apahls, and/or vis unlecro for any and all legal expenses:and costs incurred by each of them in connection therewith or in enforcing the indemnity herein provided. Contractors obligation to indemnify shall not be restricted to insurance proceeds, if any, received by the City, its officials, officers, employees, agents or volunteers. Such indemnification shall cover death or bodily injury to any person; Injury lo, lose, or tort of properly, injury ansing from the furnishing or use of any oopyrlghted or unvapyrighled composition, sacral process, or patented or unpatented invention, or any other lypa of injury, ver elhor such injury or damage occurs on or off City properly. INSURANCE: Contractor, its employees, agents, consultants, contractors and volunteers understand that certain types of activities create additional exposure of risk to City. Utdess ollrerwise waived or modpind by the City's Risk Manager, Contreclor and any agents, consultants, or subocntraclors shall similarly maintain the following insurance requirements and present the applicable valid certificates to the City of Lake Elsinore. Commorclel General Liability/Umbrella Insurance total limits shall be no less than $1,000,000 per accident and $2,000,000 general aggregate. Conkaclof shalt maintain aulanrcbile Ilebldly InsurnriN covering bodily Injury and property damage for ati acliviliae of the Cdntraotar arising out of Orin connection with the work to be performed under hills Agmamanl, irlckiding coverage for owned, hired and non -owned vehicles, in an amount of not less than $300,000 combined single limit for each occurrence. Contractor shall maintain Workers' Compensation Insurer" and Employor's Liability Insurariod for Milli or employees In an amounl nal lass ikon 31,000,000 In accordance with the IBM of the SSnta of California. Any aollGe of concellolten or n"40nowal of all Workers' Componsalluh oicias must be received by the City at (east thirty (303 rjey6 prior to such chango. The In sufar shall agrou )m waive all rights of subrogation uguinAl City, hs offinore, agents, employe as and volume ata for losses arcing from work perfotmod by Conlraclar for Cny. City and Its omplayaes mad agents shall be added as addilional insureds using ISO additlonal insured andorsamanl forn.09 20 10 or CG 20 26 (In no avmril will City accept an endorsement funtr wl(h an mdfon data later than 10130). Coverage Shall apply on a primary nap-donlrlbuting balls In rolmllon to any olhar Insuronco or self-Insumnco. primary or excess. Available to City ar any omploon or agarl of Clly. Covorage shall not ba Ilmlled to the vicariuuff liability or supervisory rola or any addilional Insured. Contraclors and subeonlraclam must mmlgiatn ihla lasuraneo requirsmeril and haven the City listed as additionally insured in accordance with the above statements, 12. CONTRACTOR NOT OFFICER, EMPLOYEE OR AGENT OF CITY. While engaged in carrying out Iha imrina and conditions OF She "simunl, Iha Conimnlof Is on indopondonl conlmctdr and not on ol6cmr, smployse Or ogont of the City. The Contractor tins no authodly, a:press or Impllcd, ten act an behalf of Iha City as an agent or reirmaanfailvo of lira City under this Agmement Is [rind the City in any obigallon. Tho Cenlractor is nol ellgibte for benefits from social security, Stale Unempfoymcr. insurance, DiAabllily Insurance or Workman's Compensation Insurance, In the event of injury, the Contractor is responsible for his/her own medical expenses. 13. PUBLICITY: Contractor shall not advertise, print or publish any promotional materials in connection with the instruction or service to be conducted under (his Agreement without the priorwrillen approval of the Director of Community Services or his/her aulhorized representative, 14. ASSUMPTION OF RISK Contractor works at his/her own risk. Contractor shall have each parlicippnt sign the City's "Wafvor & Release Agroernaril" in the form attached herel6 as Exhibit A. The Lkgnsee sholl provido the signed Waiver & Release Agreements to the City at the and of every month. 15. COLLECTION OF FEES: The Contractor agrees not to accept any registration face from sludeilla. All registration fame shall be pals directly to then City and fin 0onlfactor shall be paid at the concluecun of lhv cgufW by Ina Clly. The Conlractar may collecl addiional Foos for mawriafs and supply costs. Tho Conlroclor shelf approprialmly inform the participants or Iha addlllonal malarial Foos pdar IG rogislralian, Parligipunts may be requl rad to bring contain suppllea and materials to class. 16. PAYMENT OF FEES: City agrees to pay Contractor according to compensation provision provided on first page of this Agreement Contractor is responsible for payment to any subcontractors. 17. AMERICANS WITH DISABILITIES ACT. Contractor agrees that he/she shall make every attempt to accommodate people with physical and/or mental disabilities. 16 GENERAL COMPLIANCE WITH LAWS. Contractor shall comply with all !adoral, surge, and local laws, salutes, rules and foguimions n any manner aRocling the porlofmsncm of this Agroamdnl. By law, Conlraclor. Cmntroalgrs employees and any agreed upon subefiluto parsunn ul or su lm=raelor must comply with the raquirome!ts of cal Pup Raspureve Codo $acOn 5184 before analog in Ora aurvicos under this Agruomsnl. Cpnlmctof, Contractor's omployaes and any agraed upon substitute pe marine[ or subaentraetor haroby agma to a criminal baolkaround chock as required undur• Cal Pub Rasourcas Cvdn Section 5184 by Ilse City's Police Doperamwil If Conlmotur or any OF Carl hector'a empleyond or agreed upon suWitulo personnel or Iubconfractar &hall work wilh persona m1 eighluvn (10) years of ago or undur. Contractor, Cantroct&s ampeyans of any. *grand upon substilule personnel ar outxoonlraclor mu of be cleared by Cily prior to working with parsons of alghraen years of ago of undar. If the background chamk for Conlreclof. Conlracloes onlpksyeee or agreed upon suhelnute personnel or subcontractor ravoli s Illegal ar objaellenabfu Inlormation or ocitvIdoe, the person Id wham the background chock apps es shall be prohlbltad from providing Iha services hernundaf and, m City's sole and absolute discretion, this Agreamanl nlay be larminn told, In which on so Conlracior will he onlhlmd It no further compon sell on under thin: Agroetnont. Cgnnraolef. Contractors employees, and any agreed upon subslltule parannnai or aubconlraclar shall not be parmillod to provide sarvicas heroundor for cls uses wigs allendaaa who are clgh loan yours of ago or under unless a criminal background check has been performed and clearance has been received from the Department of Justice. 19. MODIFICATION. No waiver, modification or termination of this Agreement is valid unless made in writing, 20. NONASSIGNMENT. Contractor shall not have any right to assign and/or transfer his/her rights and/or obligations under this Agreement without the prior written consent of the City. 21. DEFAULT BY CONTRACTOR: Failure to comply with any of the terms and/or conditions of this agreement shall constitute default by the Contractor. 22. TERMINATION: 'rho agreamont may be iormbtared by the City upon 30 days' nolica given In wnhpg. Both purlies will perform In acwfdance Will this agredmml prior to the effective termination date. Nothing wriloinod herein "Ill diminish the nghl of the City to canak irlrrladlmlety and vdlhvul prior notice, the agmomvnt for causo without pdnslly or 11mbilfly on the pa11 of the City. 23, ENTIRE AGREEMENT: This contract constitutes the entire Agreement betweon lheparltas cmrmemingthe sulr[ard maruler haroof and suparoadea all agreamanls, ropreserin Uanf. awtonlarils, promises and understonclings, whether oral of wrirloo, oath fvspnci to rhe subject moaner hereof 24. SPECIAL ARRANGEMENTS: � M 3 01�•3 = .. -. 2 a i� � 3 • :moi A� ■ > > . - 1 ^_" � - .3 � IMF -=+. a � BUSINESS LICENSE CITY OF LAKE ELSINQRE This business license is issued for revenure.purposes only and does not grant aulhoiization Administrative Services - Licensing to operate a. business. This busin asOtcense is issued without verificatlon that the holder Is 130 'South Main Street, Lake Elsinore, CA 92530 subject tc or exempted from licensing by the slats, county, federal government, ar any PH (951) 674-3124 other governmental agency. Business Name: EARLYLEARNERS Business Location: 34905 BIRCHWOOD DR LAKE ELSINORE. CA 92530-2823 Owner Names): MARIA JAZMINE OELONE STEPHANIE SANGES EARLY LEARNERS 31905 BIRCHVVOOD DR LAKE ELSINQRE, CA 92530-2623 BUSINESS LICENSE NO. 017288 Business Type; CLASS INSTRUCTOR Issue Date: 71912016 Expiration Date: 613.012017 TO BE POSTED IN A CONSPICUOUS PLACE THIS IS YOUR LICENSE • NOT TRANSFERABLE EVANSTON INSURANCE COMPANY CERTIFICATE NO.: - CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Lake Elsinore Apex Insurance Services P. O. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Maria J Delone TYPE: Early learners 31905 Birchwood Drive DATE(S): 1/20/2016 — 12/31/2016 Lake Elsinore, CA 92532 LOCATION: Citv of Lake Elsinore *Liquor Liability Yes ❑ No El "Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY 1, 2017 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Oflnsurance: Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as if a.separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy 3UY I ti Il it 15 AUTHORIZED REPRESENTATIVE: DATE ISSUED: 1/20/201 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: - CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Lake Elsinore Apex Insurance Services P. O. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Maria J Delone TYPE: Ballet 31905 Birchwood Drive DATE(S): 1/20/2016 —12/3112016 Lake Elsinore, CA 92532 LOCATION: City of Lake Elsinore *Liquor Liability Yes ❑ No "Liquor Liability after 12 am ends before 2 am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: � MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2016 EXPIRATION: JANUARY 1, 2017 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Of Insurance: Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions - AUTHORIZED REPRESENTATIVE: DATE ISSUED: Auto Insurance Declaration Page FARMERS INSURANCE Policy Number: Premiums/Fees Name Effective: 6/17/2016 12:01 AM .................................................... Full-term Premium (excluding fees) $761.60 Expiration: 9/28/201612:01 AM Stephanie Sanges Covered Jazmine Delone Named lnsured(s): Jazmine Delone Prorated Premium (6/17/2016-9/28/2016) $159.08 31905 Birchwood Dr Fees for this transaction $15.88 Lake Elsinore, CA 92532-2623 Veh. # Year/Make/Model/VIN none@none.com 110- Total for this Transaction $174.96 Underwritten By: Farmers Insurance Exchange Comprehensive: $1,000 6301 Owensmouth Ave. This is not a bill. Woodland Hills, CA 91367 Your bill with the amount due will be mailed separately. Household Drivers Name Driver Status Name Driver Status Stephanie Sanges Covered Jazmine Delone Covered Vehicle Information Veh. # Year/Make/Model/VIN Coverage Deductible Limit 1 2015 Honda Civic4D SE Comprehensive: $1,000 Collision: $1,000 -------------- ........ Additional Equipment: $1,000 2 2004 Honda Civic 4D Ex .. . • • ...... . . Comprehensive: Not Covered Collision: Not Covered Additional Equipment: Not Covered Coverage Information Limits Premiums by Vehicle Coverage_(ap�7licap e to all vellicies) 1 Vehicle 2 Bodily Injury Liability _ $100,000 each person _ _ _Vehicle $236.10 $241.00 $300,000 each accident Property Damage Liability $50,000 each accident Included Included Medical Coverage Not Covered Not Covered Uninsured Motorist Bodily $100,000 each person $46.60 $45.30 Injury $300,000 each accident ... .. Comprehensive -- - . • .......... ......... ...... . ... ... .. ...- $43.30 Not Covered Collision $143.60 Not Covered Additional Equipment Included Not Covered farmers.com Policy No. Questions? Manage your account: vti�:e Call your agent Julian Palacios at (714) Go to www.farmers.com to access 529-4147 or email your account any time! jpalacios@farmersagent. com 56-6176 1stEdi[ion 4-I5 6/20/2016 Page 1 of 3 Declaration Page (continued) Rating Information Premiums by Vehicle Vehicle 1 Limits Details Vehicle 1 Vehicle 2 Coverage (,applicaL)le to all vehicles) - $5.70 Not Covered Uninsured Motorist Property See Endoisernent CA050, Damage With Collision coverage C:-2 Previous Annual Mileage Other Use Other Use Not Covered Not Covered Towing and Road Service 39-43 N/A Years of Driving Expei ience $475.30 $286.30 Total Premium Per Vehicle - - $761.60 i` Fuii-term Premium Transaction Fee Detail Vehicle 1 Vehicle 2 Total -- — -- 00 88 Ant -i -Fraud Fee .- ............................ ....:........................................_.....-...--..................__..... ....... $0.00 .....-.. ...... $15.00 .._..._... -- -- $15.00 Fees Per Vehicle _ 15.88 Fees for this Transaction Discounts Discount Type Applies to Vehicle(s) Discount Type Applies to Vehicle(s) Anti -Lock Br akes 1 Good Driver 1, 2 _...............,._......................_....... Multiple....�.ar.. 1,2 Group -Educator .. 1 Safe Driver 1,2 Stability Control Rating Information Vehicle 1 Vehicle 2 Details _ _ - — --- 92532 - - — . -. 92532 Garaging Zip 10,500 11,000 Current Annual Mileage 10,500 N/A Previous Annual Mileage Other Use Other Use Vehicle Usage 39-43 N/A Years of Driving Expei ience Policy and Endorsements Thissection ii:tsthe poli cy tornl number and any applicable endorseme-ntsthat make up your insurance contract. Any endorsements that you have purchased to extend cpVerage on your policy are also listed in the coverages section ol: this declarations document: 56-5046 4th ed.; CA030 3rd ed.; CAM:.1 st ed.; CA049 1 st ed.; CA050 1 st ed. [Veh:1 on ly]; CA080 2nd ed.; CA097 2nd ed.:16275 1 st ed.;J62841st ed.[Veh:1 only]; J6491 1st ed.;J64921st ed.;J66721st ed.;J69341st ed.; 25-8531 10-12 Other Information • You may be eligible for a different rate but with different coverage from Far mers Specialty Insurance Company. Please contact your Farmers' agent to discuss your options. • Vehicle 1 - Deductible waived if glass repaired rather than replaced. farmers.com Policy No. Questions? Manage youraccount: Call your agent Julian Palacios at (714) Go to www.farrners.com to access 529-4147 or email your account any time! jpal acios cQi farmersagentcom 56-6176 1st Fdition 4-15 Page 2 of 3 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE I hereby certify that in the performance of the work for which this Agreement is entered into, I shall not employ any person in any manner so as to become subject to the Worker's Compensation Laws of the State of California. Executed on this day of F , 2016 at Lake Elsinore, California. "Ca"rName'= Conti ctor Signature