HomeMy WebLinkAboutC-7339-7 - Dory Fishing Fleet Zone Permit7
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Dory Fishing Fleet Zone Permit
1. Permittee: This Dory Fishing Fleet Zone Permit ("Permit') is issued on
MAVZL" I , 2018 ("Effective Date") to The Dory Fishing Fleet
Association, an unincorporated nonprofit association ("Permittee") granting
Permittee the non-exclusive use of the area immediately west of the Newport Pier,
delineated by pilings erected by the City of Newport Beach (the area is hereinafter
referred to as "Dory Fishing Fleet Zone" or 'Premises") for commercial Dory
Fishing Fleet Activity, as hereinafter defined. The Dory Fishing Fleet Zone is
located upon City of Newport Beach ("City") tidelands and is more particularly
depicted in Attachment 1, attached hereto and incorporated herein by reference.
By acceptance of this Permit, Permittee agrees to be bound by the terms contained
in this Permit. City and Permittee are at times individually referred to as 'Party"
and collectively as "Parties" herein.
The Dory Fisherman Fleet Zone is a locally recognized historical resource,
identified in the City's Newport Beach Register of Historical Property in the
Historical Resources Element under Chapter 6 of the Newport Beach General
Plan. An area immediately west of the Newport Pier, delineated by pilings erected
by the City, has been reserved for full time use by Dory Fishermen.
2. Dory Fishermen: The individual fishermen and businesses that operate at the
Dory Fishing Fleet Zone are required to be members of The Dory Fishing Fleet
Association ("Members"). Permittee and each of its Members must have a Permit
to use the Dory Fishing Fleet Zone. All of the fishermen with Dory Fishing Fleet
Zone Permits are hereinafter collectively referred to as "Dory Fishermen". In
accordance with City Council Policy H-4, as shown on Attachment 2, attached
hereto and incorporated herein by reference, which was adopted on November 23,
1987, Reaffirmed on January 24, 1994 and Amended September 10, 2002, the
Dory Fishing Fleet Zone was reserved for Dory Fishermen. Dory Fishermen have
been granted non-exclusive use of the Premises for commercial Dory Fishing Fleet
Activity, defined as primarily the catching and selling of fish as well as other
ancillary uses such as: use of storage lockers; storage of Dory vessels and fishing
equipment; and the sale of seafood to the public. Permittee shall comply with all
sections of City Council Policy H-4, as may be amended from time to time.
3. Term: This Permit shall be valid for a period of ten (10) years beginning on the
Effective Date and expiring on ("AQ cJ4 t 2028 unless terminated earlier
as provided herein.
4. Rent:
A. In lieu of rent, Permittee shall operate a fish market, open to the public at
least five (5) days per week ("Dory Fishing Fleet Fish Market').
B. In accordance with City Council Policy F-7, whenever an open bid process
is not conducted or fair market value rent is not received for the use of City
Dory Fishing Fleet Zone Permit Page 1
property, the City shall make specific findings setting forth the reasons
thereof. The City finds that the Permittee provides an essential or unique
service to the community that might not otherwise be provided were full
market value of the property required. Additionally, as the Premises may
be located, in part, upon public tidelands and the rent charged is less than
fair market value the City Council finds this use provides a public benefit to
the people of California by providing affordable access to healthy and
sustainable seafood and is therefore a matter of statewide benefit. These
findings by the City are of a statewide concern in that the beneficial uses of
the property might not otherwise be provided were full market value of the
property required.
5. Utilities and Taxes: Permittee is responsible for paying utilities, all taxes, fees and
assessments for the Premises or improvements located thereon.
A. City will furnish two (2) water hose bib outlets to be shared by the Dory
Fishermen.
B. Electricity will consist of one (1) light switch, one (1) overhead light, and two
(2) plug switches per shed, with the monthly costs prorated amongst the
Dory Fishermen.
6. Use of Premises:
A. Permittee shall be generally responsible for all of the dory storage sheds
identified on Attachment 3, attached hereto and incorporated herein by
reference, which sheds have been assigned by City to individual Members
under City Permit.
i. Common Areas: The following common areas shall be shared
equally amongst the Dory Fishermen and shall be maintained in a
clean, safe condition by the Dory Fishermen: water hose bibs,
drainage areas and Dory vessels.
B. During the term of this Permit, Permittee will use and occupy the Premises
solely and exclusively operation of the Dory Fleet Fish Market and
Permittee's commercial fishing business.
C. Dory vessels allowed to be launched and stored on the public beach will be
a traditional Dory design vessel.
D. The Dory Fishing Fleet Zone is not to be used as a launching facility for
itinerant commercial or sport fishing enterprises.
E. The use of vehicles to launch and retrieve boats during the summer months
and the weekends in the spring and fall when beach use is heavy will be
restricted to the hours before 11:00 a.m. and after 6:00 p.m. Vehicles and
trailers used by the Dory Fishermen will be parked in a location and manner
Dory Fishing Fleet Zone Permit Page 2
prescribed by City's Fire Department and per the map in Attachment 1.
Permittees vehicles shall not interfere with lifeguard, fire, police, or other
City operations.
F. The Dory Fishermen assume full responsibility for operation and
maintenance and repair of the Premises and associated improvements
throughout the term of this Permit at its sole cost, and without expense to
the City.
G. The dory sheds permitted within the designated boundaries are to be used
by the Dory Fishermen only for the storage of equipment and supplies and
are not to be used for temporary or permanent housing occupancy.
H. There shall be a maximum of twenty (20) dory storage sheds, no larger than
the dimensions set forth in City Council Policy H-4, as may be amended
from time to time. The size, type of construction and architectural style shall
be developed with input from the Dory Fishermen.
I. The Dory Fishermen will abide by all City Ordinances and California Boating
Laws in the operation of their vessels near the beach and surf zone where
there are swimmers and surfers. Dory vessels will ingress and egress
immediately ocean ward of their designated beach zone, which is depicted
Attachment 1.
7. Conditions of Use:
A. Each Member of Permittee shall individually obtain and maintain a current
City business license.
B. Each Member of Permittee shall individually obtain and maintain a
commercial fishing license, as may be required by California Department of
Fish and Wildlife.
C. Permittee or each of its Members shall obtain and maintain any required
permits and approvals from the Orange County Environmental Health
Department.
D. Permittee or each of its Members shall provide the Real Property
Administrator with a copy of all required licenses, permits and certificates
that may be required of Permittee.
E. Permittee and each of its Members shall comply with all local, state, and
federal requirements for fishing and selling fish to the public.
8. Condition of the Premises:
A. Permittee agrees to accept the Premises in an 'as is' condition as tendered
by City. Permittee agrees that no representations with respect to the
Dory Fishing Fleet Zone Permit Page 3
condition or improvements of the Premises have been made by City except
as specifically set forth in this Permit, and are otherwise being delivered in
an 'as in' condition.
B. Any changes, alterations or improvements to the Premises require the prior
written consent of the City Manager or his/her designee.
Possessory Interest Tax Notice: The City hereby gives notice to the Permittee,
pursuant to Revenue and Tax Code Section 107.6 that this Permit may create a
possessory interest that is the subject of property taxes levied on such interest, the
payment of which taxes shall be the sole obligation of the Permittee. The Permittee
shall advise in writing any sublessee, licensee, concessionaire or third party using
the Premises of the requirements of Section 107.6.
10. Compliance With Applicable Laws: The Permittee is required at its sole expense
to comply with all applicable City, County, State and Federal laws and regulations.
11.Transfer/Assignment: This Permit may not be transferred or assigned by the
Permittee without the City's prior written consent. Transfer/assignment without the
City's prior written consent is null and void.
12. No Third Party Rights. The Parties do not intend to create rights in or grand
remedies to, any third party as a beneficiary of this Permit, or of any duty, covenant,
obligation or undertaking established herein.
13. Notices. All notices and other communications required or to be given under the
terms of this Permit, including any notice of change of address, shall be given in
writing, and conclusively shall be deemed served when delivered personally, or on
the third business day after the deposit thereof in the United States mail, postage
prepaid, first-class mail, addressed as hereinafter provided. Notice shall be given
as follows:
To City: City of Newport Beach
Attn: Real Property Administrator
PO Box 1768
100 Civic Center Drive
Newport Beach, CA 92658
949-644-3236
To Permittee: The Dory Fishing Fleet Association
Attn: Scott Breneman
2111 W. Oceanfront Blvd.
Newport Beach, CA 92663
Dory Fishing Fleet Zone Permit Page 4
14. Termination:
A. This Permit may be terminated for cause (e.g., failure to abide by the terms
of this Permit) by the City with no less than seven (7) calendar days prior
written notice to the Permittee. In the event of termination under this
section, the City shall owe no compensation to the Permittee and the
Permittee shall remove all personal property from the Premises within
fifteen (15) calendar days. Alternatively, the Permittee, with the City's prior
written consent, may quitclaim all fixtures, equipment, and improvements
on the Premises to the City. Notwithstanding any other provision of this
Permit as permitted by California Public Resources Code Section 6312, or
any successor statute, the parties agree that upon expiration or earlier
termination of this Permit the City shall have no liability or obligation to pay
compensation for any improvements made to the Premises.
B. Notwithstanding any other provision of this Permit, either party shall have
the right to terminate this permit at any time and for any reason upon thirty
(30) calendar days' written notice to the other Party.
15. Inspection: Upon twenty-four (24) hours' notice, the City may enter the Premises,
and all improvements thereon, to inspect the Premises for compliance with the
terms of this Permit.
16. Indemnity and Exculpation:
A. Hold -Harmless Clause. To the fullest extent permitted by law, Permittee
shall indemnify, defend (with Counsel selected by the City) and hold
harmless the City, its elected officials, officers, employees, agents,
attorneys, volunteers, and representatives (collectively, the "Indemnified
Parties") from and against any and all claims (including, without limitation,
claims for bodily injury, death or damage to property), demands, obligations,
damages, actions, causes of action, suits, losses, judgments, fines,
penalties, liabilities, costs and expenses (including, without limitation,
attorney's fees, disbursements and court costs) of every kind and nature
whatsoever (individually, a "Claim"; collectively, "Claims"), which may arise
from or in any manner relate (directly or indirectly) to Permittee's
possession, occupation or use of the Premises, specifically including,
without limitation, any claim, liability, loss, or damage arising by reason of:
i. The death or injury of any Person or damage to personal property
caused or allegedly caused by the condition of the Premises or an
act or omission of Permittee or an agent, contractor, subcontractor,
supplier, employee, servant, or sublessee of Permittee;
ii. Any work performed on the Premises or materials furnished to the
Premises at the request of Permittee or any agent or employee of
Permittee, with the exception of Maintenance performed by City;
and/or
Dory Fishing Fleet Zone Permit Page 5
iii. Permittee's failure to perform any provision of this Permit or to
comply with any requirement of Law or any requirement imposed on
the Premises by any duly authorized governmental agency or
political subdivision.
Permittee's obligations pursuant to this Subsection shall not extend to any
Claim proximately caused by the sole negligence, willful misconduct, or
unlawful or fraudulent conduct on the part of the Indemnified Parties. This
indemnity shall apply to all claims and liability regardless of whether any
insurance policies are applicable.
B. Exculpation of City. Except as otherwise expressly provided in this Permit,
City shall not be liable to Permittee for any damage to Permittee or
Permittee's property from any cause other than the sole negligence,
intentional or willful acts of the Indemnified Parties. Except as otherwise
expressly provided in this Permit, Permittee waives all claims against the
Indemnified Parties arising for any reason other than the sole negligence,
intentional or willful acts of the Indemnified Parties. City shall not be liable
to Permittee for any damage to the Premises, Permittee's property,
Permittee's goodwill, or Permittee's business income, caused in whole or in
part by acts of nature such as earthquakes, floods, fire or other natural
disaster.
17. Insurance:
A. Without limiting Permittee's indemnification of City, Permittee will obtain on
behalf of its Members, and provide and maintain at its own expense during
the term of this Permit, a policy or policies of insurance of the type, amounts
terms and conditions described in the Insurance Requirements attached
hereto as Attachment 4, and incorporated herein by reference.
B. Permittee is required to insure Permittee's own, and that of its Members,
personal property and any tenant improvements that Permittee and/or its
Members has/have made to the Premises.
18. No Damages: The Permittee acknowledges the City would not have issued this
Permit if it were to be liable for damages under, or relating to, this Permit. The
parties agree that declaratory relief, injunctive relief, mandate and specific
performance shall be the Permittee's sole and exclusive judicial remedies.
[SIGNATURES ON NEXT PAGE]
Dory Fishing Fleet Zone Permit Page 6
IN WITNESS WHEREOF, the parties hereto have caused this Permit to be
executed in duplicate on the date and year first written herein.
APPROVED AS TO FORM: CITY OF NEWPORT BEACH,
CITY ATTORNEY'S OFFICE a California municipal corporation
Date: b 8 Date: aA►,g
By: �— (�.• 1 By:
Aaron C. Harp Dave Kill
City Attorney City Manager
ATTEST: PERMITTEE: The Dory Fishing Fleet
Date: Association, an unincorporated nonprofit
association c/
Date: Z / 16
By: itis By:^'� �—
Leilani I. Bro Steve Escobar
City Clerk ,,aEm=,p, Authorized Member
D OF SIGNATURES]
Attachments: -4*�rnent 1 — Depiction of Premises & Uplands Support
Attachment 2 — Council Policy H-4
Attachment 3 — Shed Assignments
Attachment 4 — Insurance Requirements
[END OF SIGNATURES]
Dory Fishing Fleet Zone Permit Page 7
Attachment 1
Description of Premises & Uplands Support
Dory Fishing Fleet Zone Permit Page 8
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Attachment 2
City Council Policy H-4
Dory Fishing Fleet Zone Permit Page 9
H-4
DORY FISHERMENS' FLEET
It is a general policy of the City of Newport Beach that an area immediately west of the
Newport Pier be reserved for the Newport Dory Fishermens' Fleet. The dory fishing
fleet, founded in 1891, is a historical landmark designated by the Newport Beach
Historical Society.
The City Council, in developing an official position with respect to the dory fishing
fleet, has examined and evaluated the following:
A. The historical significance and relative size of the fishing fleet;
B. The desirability of preserving a small area of public beach for commercial dory
fishing fleet activity, primarily for catching and selling fish; and
C. The responsibility of the City to protect the health, safety and welfare of beach
users and swimmers in the vicinity of the dory fleet.
After considering these factors, the Newport Beach City Council has adopted policy
provisions concerning the Dory Fishermens' Fleet operations.
A. The dory fishing fleet zone is delineated by pilings erected by the City and is
reserved for full time Dory Fishermen who derive their livelihood from
commercial fishing. Dory Fishermen are required to maintain a current
commercial fishing license.
B. Dory Fishermen will have a current City business license.
C. Dory fishing vessels allowed to be launched and stored on the public beach will
be a traditional dory design vessel.
D. The dory fishing fleet zone is not to be used as a launching facility for itinerant
commercial or sport fishing enterprises.
E. The use of vehicles to launch and retrieve boats during the summer months and
weekends in the spring and fall when beach use is heavy, will be restricted to the
hours before 11:00 a.m. and after 6:00 p.m. Vehicles and trailers used by the dory
fleet will be parked in a location and manner prescribed by the Fire Department.
1
H-4
F. The dory fishing fleet will be responsible for cleanup and maintenance of the
designated dory fleet zone.
G. The City will furnish two water hose bib outlets to be shared by the Dory
Fishermen. Electricity will consist of one light switch and one plug switch per
shed, with the monthly costs prorated amongst the shed assignees.
H. The dory sheds permitted within the designated boundaries are to be used by the
Dory Fishermen only for the storage of equipment and supplies and are not to be
used for temporary or permanent housing occupancy.
I. There shall be a maximum of 20 dory storage sheds no larger than 10' by 10',
with roof ridge heights not to exceed 9 feet. The size, type of construction and
architectural style shall be developed with input from the dory fleet.
J. The Dory Fishermen will abide by all City ordinances and California Boating
Laws in the operation of their vessels near the beach and surf zone where there
are swimmers and surfers. Dory vessels will ingress and egress immediately
ocean ward of their designated beach zone.
K. The dory fishing fleet may designate a spokesperson to represent their concerns
and will meet with appropriate City department(s), as designated by the City
Manager to resolve conflicts of use and safety problems.
Adopted - November 23,1987
Reaffirmed - January 24,1994
Amended - September 10, 2002
2
Attachment 3
Shed Assignments
Dory Fishing Fleet Zone Permit Page 10
Attachment 4
INSURANCE REQUIREMENTS - PERMIT
1. Provision of Insurance. Without limiting Permittee's and its Members'
indemnification of City, Permittee shall obtain, provide and maintain at its own
expense during the term of this Permit, policies of insurance of the type and
amounts described below and in a form satisfactory to City. Permittee agrees
to provide insurance in accordance with requirements set forth here. If
Permittee uses existing coverage to comply and that coverage does not meet
these requirements, Permittee agrees to amend, supplement or endorse the
existing coverage.
2. Acceptable Insurers. All insurance policies shall be issued by an insurance
company currently authorized by the Insurance Commissioner to transact
business of insurance in the State of California, with an assigned policyholders'
Rating of A- (or higher) and Financial Size Category Class VII (or larger) in
accordance with the latest edition of Best's Key Rating Guide, unless otherwise
approved by the City's Risk Manager.
3. Coverage Requirements.
A. Workers' Compensation Insurance. Permittee shall maintain Workers'
Compensation Insurance, statutory limits, and Employer's Liability
Insurance with limits of at least one million dollars ($1,000,000) each
accident for bodily injury by accident and each employee for bodily injury by
disease in accordance with the laws of the State of California, Section 3700
of the Labor Code.
Permittee shall submit to City, along with the certificate of insurance, a
Waiver of Subrogation endorsement in favor of City, its officers, agents,
employees and volunteers.
B. General Liability Insurance. Permittee shall maintain commercial general
liability insurance, and if necessary umbrella liability insurance, with
coverage at least as broad as provided by Insurance Services Office form
CG 00 01, in an amount not less than one million dollars ($1,000,000) per
occurrence, two million dollars ($2,000,000) general aggregate. The policy
shall cover liability arising from premises, operations, personal and
advertising injury, and liability assumed under an insured contract (including
the tort liability of another assumed in a business contract).
Permittee shall submit to City, along with the certificate of insurance, a
Waiver of Subrogation endorsement in favor of City, its officers, agents,
employees and volunteers.
Dory Fishing Fleet Zone Permit Page 11
C. Property Insurance. Permittee shall maintain property insurance in an
amount not less than one hundred thousand dollars ($100,000.00). The
policy shall cover Permittee's personal property and tenants' improvements.
4. Other Insurance Requirements. The policies are to contain, or be endorsed to
contain, the following provisions:
A. Waiver of Subrogation. All insurance coverage maintained or procured
pursuant to this Permit shall be endorsed to waive subrogation against
City, its elected or appointed officers, agents, officials, employees and
volunteers or shall specifically allow Permittee or others providing
insurance evidence in compliance with these requirements to waive their
right of recovery prior to a loss. Permittee and its Members hereby
waives its/their own right of recovery against City, and shall require
similar written express waivers from each of its subconsultants.
B. Additional Insured Status. All liability policies including general liability,
excess liability, pollution liability, and automobile liability, if required, but
not including professional liability, shall provide or be endorsed to
provide that City and its officers, officials, employees, and agents shall
be included as insureds under such policies.
C. Primary and Non Contributory. All liability coverage shall apply on a
primary basis and shall not require contribution from any insurance or
self-insurance maintained by City.
D. Notice of Cancellation. All policies shall provide City with thirty (30)
calendar days' notice of cancellation (except for nonpayment for which
ten (10) calendar days' notice is required) or nonrenewal of coverage for
each required coverage.
5. Additional Agreements Between the Parties. The parties hereby agree to the
following:
A. Evidence of Insurance. Permittee shall provide certificates of insurance
to City as evidence of the insurance coverage required herein, along
with a waiver of subrogation endorsement for workers' compensation
and other endorsements as specified herein for each coverage.
Insurance certificates and endorsement must be approved by City's Risk
Manager prior to commencement of performance. Current certification
of insurance shall be kept on file with City at all times during the term of
this Permit. City reserves the right to require complete, certified copies
of all required insurance policies, at any time.
B. City's Right to Revise Requirements. City reserves the right at any time
during the term of the Permit to change the amounts and types of
insurance required by giving Permittee sixty (60) calendar days advance
written notice of such change. If such change results in substantial
Dory Fishing Fleet Zone Permit Page 12
additional cost to Permittee, City and Permittee may renegotiate
Permittee's compensation.
C. Enforcement of Permit Provisions. Permittee acknowledges and agrees
that any actual or alleged failure on the part of City to inform Permittee
of non-compliance with any requirement imposes no additional
obligations on City nor does it waive any rights hereunder.
D. Requirements not Limiting. Requirements of specific coverage features
or limits contained in this Section are not intended as a limitation on
coverage, limits or other requirements, or a waiver of any coverage
normally provided by any insurance. Specific reference to a given
coverage feature is for purposes of clarification only as it pertains to a
given issue and is not intended by any party or insured to be all inclusive,
or to the exclusion of other coverage, or a waiver of any type. If the
Permittee maintains higher limits than the minimums shown above, the
City requires and shall be entitled to coverage for higher limits
maintained by the Permittee. Any available insurance proceeds in
excess of the specified minimum limits of insurance and coverage shall
be available to the City.
E. Self-insured Retentions. Any self-insured retentions must be declared
to and approved by City. City reserves the right to require that self-
insured retentions be eliminated, lowered, or replaced by a deductible.
Self-insurance will not be considered to comply with these requirements
unless approved by City.
F. City Remedies for Non -Compliance. If Permittee, its Members, or any
subconsultant fails to provide and maintain insurance as required herein,
then City shall have the right but not the obligation, to purchase such
insurance, to terminate this Permit, or to suspend Permittee's, or its
Members' right to proceed until proper evidence of insurance is
provided. Any amounts paid by City shall, at City's sole option, be
deducted from amounts payable to Permittee or reimbursed by
Permittee upon demand.
G. Timely Notice of Claims. Permittee, or its Members, shall give City
prompt and timely notice of claims made or suits instituted that arise out
of or result from Permittee s performance under this Contract, and that
involve or may involve coverage under any of the required liability
policies. City assumes no obligation or liability by such notice, but has
the right (but not the duty) to monitor the handling of any such claim or
claims if they are likely to involve City.
H. Permittee's Insurance. Permittee and its Members shall also procure
and maintain, at its own cost and expense, any additional kinds of
Dory Fishing Fleet Zone Permit Page 13
insurance, which in its own judgment may be necessary for its proper
protection and prosecution of the Work.
Dory Fishing Fleet Zone Permit Page 14
CERTIFICATE OF INSURANCE
CHECKLIST
City of Newport Beach
This checklist Is comprised of requirements as outlined by the City of Newport Beach. *
Date Received: 9/26/2019 Dept./Contact Received From: Fauna Shrago
Department: CDD Sent to: Marissa By.
Fauna
Company/Person required to have certificate: Dory Fleet Fishing Association
E] Yes
Type of contract: Other
I. GENERAL LIABILITY
EFFECTIVE/EXPIRATION DATE: 8/12/2019-8/19/2020
A. INSURANCE COMPANY: Alain Specialty Insurance Company
B. AM BEST RATING (A-: VII or greater): A:VII
C. ADMITTED Company (Must be California Admitted):
Is Company admitted in California?
❑ Yes [Z]No
D. LIMITS (Must be $1M or greater): What is limit provided?
$1M occur/ $2M agg
E. ADDITIONAL INSURED ENDORSEMENT — please attach
❑✓ Yes ❑ No
F. ADDITIONAL INSURED WORDING TO INCLUDE (The City
its officers, officials, employees and volunteers): Is it
included?
❑ Yes ❑✓ No
G. PRIMARY & NON-CONTRIBUTORY WORDING (Must be
included): Is it included?
❑✓ Yes ❑ No
H. PRODUCTS AND COMPLETED OPERATIONS (Must
include): Is it included? (completed Operations status does
not apply to Waste Haulers or Recreation)
N/A ❑ Yes ❑ No
II.
AUTOMOBILE LIABILITY
EFFECTIVE/EXPIRATION DATE: not required by contract
A. INSURANCE COMPANY:
B. AM BEST RATING (A-: VII or greater)
C. ADMITTED COMPANY (Must be California Admitted):
Is Company admitted in California?
D. LIMITS - If Employees (Must be $1M min. BI & PD and $500,000
UM, $2M min for Waste Haulers): What is limits provided?
E. PRIMARY & NON-CONTRIBUTORY WORDING
ENDORSEMENT -please attach
F. HIRED AND NON -OWNED AUTO ONLY:
G. ADDITIONAL INSURED ENDORSEMENT — please attach
H. ADDITIONAL INSURED WORDING TO INCLUDE (The City its
officers, officials, employees and volunteers): Is it included?
I. SIGNED AUTOMOBILE INSURANCE EXEMPTION FORM:
❑ Yes ❑ No
❑ Yes
❑ No
❑N/A ❑Yes
[:]No
E] Yes
❑ No
❑Yes ❑ No
❑✓ N/A ❑Yes ❑ No
III.
WORKERS' COMPENSATION
EFFECTIVE/EXPIRATION DATE: Signed Declaration of Exemption
A. INSURANCE COMPANY:
B. AM BEST RATING (A-: VII or greater):
C. ADMITTED Company (Must be California Admitted):
[]Yes ❑ No
D. WORKERS' COMPENSATION LIMIT: Statutory
E] Yes ❑ No
E. EMPLOYERS' LIABILITY LIMIT (Must be $1M or greater)
F. WAIVER OF SUBROGATION (To include): Is it included?
❑ Yes ❑ No
G. SIGNED WORKERS' COMPENSATION EXEMPTION FORM:
❑ N/A ❑✓ Yes ❑ No
ADDITIONAL COVERAGES THAT MAYBE REQUIRED
❑
PROFESSIONAL LIABILITY
EFFECTIVE/EXPIRATION DATE:
A. INSURANCE COMPANY:
❑
POLLUTION LIABILITY
EFFECTIVE/EXPIRATION DATE:
A. INSURANCE COMPANY:
❑
BUILDER'S RISK
EFFECTIVE/EXPIRATION DATE:
A. INSURANCE COMPANY:
EFFECTIVE/EXPIRATION DATE:
A. INSURANCE COMPANY:
General Liability non -admitted carrier approved as surplus lines carrier
Property insurance requirement waived - each member signing waiver
Approved:
r
3/5/2020
Risk Management Date