HomeMy WebLinkAboutCommunity Care Health Centers - 2007-11-05AGREEMENT BETWEEN
THE CITY OF HUNTINGTON BEACH
AND
COMMUNITY CARE HEALTH CENTERS
(Program No. B-07-MC-06-0506)
FOR PROGRAM YEAR 2007/2008
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) FUNDS
THIS AGREEMENT, made and entered into by and between the CITY of HUNTINGTON
BEACH a municipal corporation, hereinafter referred to as "City", and COMMUNITY CARE
HEALTH CENTERS hereinafter referred to as "Subrecipient".
RECITALS
WHEREAS, the City has applied for and received funds from the United States
Government under Title I of the Housing and Community Development Act of 1974, Public Law
93-383; and
WHEREAS, the City wishes to engage the Subrecipient to assist the City in utilizing such
funds; and
WHEREAS, the City has environmental clearance to release the funds for this project;
NOW, THEREFORE, in consideration of these recitals, and the mutual covenants
contained herein, City and Subrecipient agree as follows:
1) National Obiective
The Subrecipient certifies that the activities carried out with funds provided under this
Agreement will meet the CDBG program's National Objective of benefit to low/moderate
income persons as defined in 24 CFR Part 570.208.
The Subrecipient shall adhere to the terms of the City's CDBG Application and Subrecipient
Agreement and with assurances and agreements made by the City to the United States
Department of Housing and Urban Development.
2) Subrecipient Grant Amount and Scope of Work
The City has allocated Federal 2007-2008 CDBG funds in the amount of Fifty Thousand
Dollars ($50,000.00) to the Subrecipient to assist with the program costs for activities
described in the Scope of Work (Exhibit A).
3) Time of Performance
The services described above are generally provided on a weekly basis to eligible persons.
Reimbursable activities per this Grant Agreement may begin on October 1, 2007 and shall
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end on September 30, 2008.
4) Personnel Assigned
Subrecipient personnel assigned to carry out the Scope of Work shall, if required by the
standards of their profession, maintain all licenses and permits necessary to remain in
compliance with State and Federal requirements governing the profession. The City shall be
notified of all personnel assigned to carry out the Scope of Work and shall be notified if
there is a change in personnel.
5) Levels of Performance
The Subrecipient agrees to provide the levels of program service as described in the Scope
of Work (Exhibit A).
6) Budget
The budget (Exhibit B) as proposed in the Subrecipient Grant application shall be the
governing budget for this grant agreement and is incorporated herein by reference unless
modified and approved in writing by the City prior to this agreement.
In addition, the City may request a more detailed budget breakdown than originally
proposed and the Subrecipient shall provide such supplementary budget information in a
timely fashion in the form and content prescribed by the City. Both the City and
Subrecipient must approve any amendments to the budget in writing.
7) Proiect Schedule[Milestones
Services of the Subrecipient shall start no sooner than on the first day of October 2007 and
end on the thirtieth day of September 2008.
Every effort shall be made by the Subrecipient to expend the allocated funds in their entirety
by September 30, 2008. If the Subrecipient does not expend all funds by September 30,
2008, the City may reallocate the funds not yet drawn to another eligible CDBG project.
8) Compensation and Method of Payment
The City shall reimburse the Subrecipient with CDBG funds for program costs related to
eligible services to not exceed the grant amount for the period beginning October 1, 2007
and ending September 30, 2008.
The City shall not provide any payments/reimbursements in advance of actual expenditures
by the Subrecipient. Funding is contingent upon the City receiving Community
Development Block Grant funds from HUD.
The Subrecipient shall submit to the City a "Reimbursement Request" within thirty (30)
calendar days after the end of the first three quarters. The reimbursement request for the
fourth quarter is due by the October 15, 2008. The reimbursement requests shall include
documentation to verify that the expenditure of funds is consistent with the project
description/definition as approved. Prior to reimbursing the Subrecipient, the City will
verify that the Subrecipient has met all applicable regulations for the project.
Payroll records, receipts, paid invoices including an itemized statement of all costs are
07-1221n4243 Page 2 of 12
samples of appropriate methods of reimbursement documentation. The Activity Report
(Section 11) is due at the same time as the reimbursement request.
The Subrecipient may request reimbursement of up to one fourth (1 /4) of the grant amount
for the following quarterly periods, unless receipts and appropriate documentation can be
provided to, and approved by, the City indicating the need to request funds greater than one
fourth (1 /4).
1 st Quarter - 10/07 through 12/08
2nd Quarter -01/08 through 03/08
3rd Quarter - 04/08 through 07/08
4th Quarter - 08/08 through 09/08
9) Program Income
The Subrecipient shall report to the City any interest or other income earned as a direct
result of the use of Federal CDBG funds for the program outlined within this agreement. All
reported program income may be retained by the Subrecipient for services in connection
with providing housing, utilities, funds for medications, computer training and food to the
homeless or those who are at risk of homelessness. All provisions of this Agreement shall
apply to these activities. The program income, retained by the Subrecipient, must be
expended before additional funds are requested from the City. Any program income on
hand when the Agreement expires or received after the Agreement's expiration shall be paid
to the City. The requirements are set forth in the Code of Federal Regulations, Title 24,
Section 570.504(c).
10) Record Keeping Requirements
The Subrecipient shall, at minimum, maintain the following records and reports to assist the
City in complying with its record keeping requirements.
a) Documentation of the income level, ethnicity, age of persons and/or households
participating in or benefiting from the Subrecipient's program;
b) Documentation of the number of persons and/or households participating in or
benefiting from the Subrecipient's program;
c) Documentation of all CDBG funds received from the City;
d) Documentation of expenses as identified in the quarterly report and
reimbursement requests;
e) Documentation of how and when a determination was made as to the eligibility
status of persons assisted, and
f) Any such other related records as the City shall require.
The Subrecipient shall maintain separate accounting records for the Federal CDBG funds
provided by the City. The City, Federal Grantor Agency, Comptroller General of the United
States, or any of their duly authorized representatives shall have access to all books,
documents, papers and records maintained by the Subrecipient which directly pertain to the
above project for the purpose of audit, examination, excerpts and transcriptions.
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11) Reporting Requirements
The Subrecipient shall submit "Quarterly Activity Reports" at the same time as the
reimbursement request within thirty (30) calendar days of the end of the first three quarters.
The final quarterly report is due no later than October 15, 2007. Quarterly reports shall be
provided by the Subrecipient to the City indicating the number of persons assisted, income
and ethnicity of persons assisted, how/what assistance was provided, and a description of
how and when determination of eligibility status was made for persons assisted. The report
must include sufficient information to assist the City in monitoring the Subrecipient's
performance. The Subrecipient must demonstrate satisfactory performance prior to
reimbursement for expenditures.
12) Public Access to Program Records
The Subrecipient shall furnish and cause each of its own subrecipients or subcontractors to
furnish all information and reports required hereunder and will permit access to its books,
records and accounts by the City, HUD or its agent, or other authorized Federal officials for
purposes of investigation to ascertain compliance with the rules, regulations and provisions
stated herein.
13) Records Retention
Unless otherwise notified by the City, the Subrecipient shall retain all financial records,
supporting documents and statistical reports related to the project identified under this
Agreement until June 30, 2011. All records subject to an audit finding must be retained for
five (5) years from the date the finding is made or until the finding has been cleared by
appropriate officials and the Subrecipient has been given official written notice.
14) Grant Closeout Procedures
The Subrecipient's obligation to the City shall not end until all close-out requirements are
completed. Activities during this close-out period shall include, but are not limited to:
making final payments, disposing of program assets (including the return of all unused
materials, equipment, unspent cash advances, program income balances, and accounts
receivable to the City), and determining the custodianship of records. Not withstanding the
foregoing, the terms of this Agreement shall remain in effect during any period that the
Subrecipient has control over CDBG funds, including program income.
15) Uniform Administrative and Program Management Standards
The Subrecipient shall comply with applicable Uniform Administrative Requirements as
described in Section 570.502 of the federal regulations for the CDBG Program. The Federal
requirements are incorporated herein by reference.
16) Use and Reversion of Assets
Upon expiration of this Agreement, the Subrecipient shall transfer to the City any CDBG
funds on hand at the time of expiration and any accounts receivable attributable to the use of
CDBG funds. The Subrecipient shall be required to use any real property under the
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Subrecipient's control that was acquired or improved in whole or in part with CDBG funds
in excess of $25,000 as follows:
a) Used to meet one of the National Objectives in 24 CFR, Section 570.208 until
five (5) years after expiration of this Agreement; or,
b) Disposed of in .a manner that results in the City being reimbursed in the amount
of the current fair market value of the property less any portion of the value
attributable to expenditure of non-CDBG funds for acquisition or improvement
to the property, Reimbursement is not required after the period of time specified
in paragraph (a) of this section.
17) Real Property
The use and disposition of real property and equipment under this Agreement shall be in
compliance with the requirements of 24 CFR Part 84 and 24 CFR 570.502, 570.503, and
570.504, as applicable, which include but are not limited to the following:
The Subrecipient shall transfer to the City any CDBG funds on hand and any accounts
receivable attributable to the use of funds under this Agreement at the time of expiration,
cancellation, or termination.
Real property under the Subrecipient's control that was acquired or improved, in whole or in
part, with funds under this Agreement in excess of $25,000 shall be used to meet one of the
CDBG National Objectives pursuant to 24 CFR 580.208 until five (5) years after expiration
of this Agreement [or such longer period of time as the City deems appropriate]. If the
Subrecipient fails to use CDBG-assisted real property in a manner that meets a CDBG
National Objective for the prescribed period of time, the Subrecipient shall pay the City an
amount equal to the current fair market value of the property less any portion of the value
attributable to expenditures of non-CDBG funds for acquisition of, or improvement to, the
property. Such payment shall constitute program income to the City. The Subrecipient may
retain real property acquired or improved under this Agreement after the expiration of the
five-year period [or such longer period of time as the City deems appropriate].
In all cases in which equipment acquired, in whole or in part, with funds under this
Agreement, is sold, the proceeds shall be program income) prorated to reflect the extent to
that funds received under this Agreement were used to acquire the equipment). Equipment
not needed by the Subrecipient for activities under this Agreement shall be (a) transferred to
the City for the CDBG program or (b) retained after compensating the City [an amount
equal to the current fair market value of the equipment less the percentage of non-CDBG
funds used to acquire the equipment].
18) Other Program Requirements
Reserved.
19) Suspension and Termination
In accordance with Title 24, Sections 85,43 and 85.44 of the Code of Federal Regulations,
this Agreement may be suspended or terminated if the Subrecipient fails to comply with any
term(s) of the award and/or the award is terminated for convenience. Title 24, Sections
85.43 and 85.44 of the Code of Federal Regulations are incorporated herein by reference as
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provisions of the Agreement.
20) Compliance with Laws and Regulations
The Subrecipient agrees to comply with the requirements of Title 24 of the Code of Federal
Regulations, Part 570 (the U.S. Housing and Urban Development regulations concerning
Community Development. Block Grants (CDBG) including subpart K (Attachment 3),
except that:
a) The Subrecipient will not assume the City's environmental responsibilities as
described on Section 570.604; and
b) The Subrecipient will not assume the City's responsibility for initiating the
review process required under the provisions of 24 CFR Part 52.
The Subrecipient also agrees to comply with all other applicable Federal, state and local
laws, regulations, and policies governing the funds provided under this contract. The
Subrecipient further agrees to utilize funds available under this Agreement to supplement
rather than supplant funds otherwise available.
21) Antidiscrimination/Affirmative Action & Equal Employment Opportunity
The Subrecipient shall comply with all State and Federal laws regarding nondiscrimination
in the provision of services and the equal opportunity employment of personnel.
22) Financial Management
Accounting Standards. The Subrecipient agrees to comply with 24 CFR 84.21-28 and
agrees to adhere to the accounting principles and procedures required therein, utilize
adequate internal controls, and maintain necessary source documentation for all costs
incurred.
Cost Principles. The Subrecipient shall administer its program in conformance with OMB
Circulars A-122, "Cost Principles for Non -Profit Organizations," or A-21, "Cost Principles
for Educational Institutions," as applicable. These principles shall be applied for all costs
incurred whether charged on a direct or indirect basis.
23) Audit Requirement
If the Subrecipient shall receive more than $300,000 in total federal funds in one fiscal year
from the City of Huntington Beach and/or any other city or agency, the Subrecipient is
required to submit a Single Audit Report. As required by the Federal Single Audit Act, the
Subrecipient shall be required to submit to the City, a comprehensive financial audit
prepared by an independent, neutral third party auditor. The audit shall cover financial
operations of the Subrecipient for the period beginning October 1, 2006 and ending
September 30, 2007 and is due not later than one year after expiration of this Agreement.
24) Religious and Lobbying Activities
Religious Activities. The Subrecipient agrees that funds provided under this contract will
not be utilized for religious activities or to promote religious interests. Religious entities
may use CDBG funds for secular activities only in accordance with the Federal regulations
specified in 24 CFR 570.2000), such as worship, religious instruction, or proselytization.
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Lobbying. The Subrecipient hereby certifies that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of it,
to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or cooperative
agreement;
(2) If any funds other than Federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or any
employee of a Member of Congress in connection with this Federal contract, grant
loan, or cooperative agreement, it will complete and submit Standard Form-LLL,
"Disclosure Form to Report Lobbying," in accordance with its instructions; and
(3) It will require that the language of paragraph (d) of this certification be included in
the award documents for all subawards at all tiers (including subcontracts, subgrants,
and contracts under grants, loans, and cooperative agreements) and that all
Subrecipients shall certify and disclose accordingly:
Lobbying Certification. This certification is a material representation of fact upon which
reliance was placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction imposed by section
1352, title 31, U.S.C. Any person who fails to file the required certification shall be subject
to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
25) Budget Modifications
If the Subrecipient desires to modify the use of the CDBG funds following approval of this
agreement, a written request must be submitted to the City for review. No change in use of
the CDBG funds will permitted without prior written approval by the City, subject to the
provisions of the City's adopted Citizen Participation Plan.
26) Performance MVlonitorin�
The City will monitor the performance of the Subrecipient against goals and performance
standards required herein. Substandard performance as determined by the City will
constitute non-compliance with this Agreement. If action to correct such substandard
performance is not taken by the Subrecipient within a reasonable period of time after being
notified by the City, contract suspension or termination procedures will be initiated.
27) Conflict of Interest
The Subrecipient agrees to abide by the provisions of 24 CFR 84.42 and 570.611, which
include (but are not limited to) the following:
1) The Subrecipient shall maintain a written code or standards of conduct that shall govern
the performance of its officers, employees or agents engaged in the award and
07-1221/14243 Page 7 of 12
administration of contracts supported by Federal funds.
2) No employee, officer or agent of the Subrecipient shall participate in the selection, or in
the award, or administration of, a contract supported by Federal funds if a conflict of
interest, real or apparent, would be involved.
3) No covered persons who exercise or have exercised any functions or responsibilities
with respect to CDBG-assisted activities, or who are in a position to participate in a
decision -making process or gain inside information with regard to such activities, may
obtain a financial interest in any contract, or have a financial interest in any contract,
subcontract, or agreement with respect to the CDBG-assisted activity, or with respect to
the proceeds from the CDBG-assisted activity, either for themselves or those with whom
they have business or immediate family ties, during their tenure or for a period of one (1)
year thereafter. For purposes of this paragraph, a "covered person" includes any person
who is an employee, agent, consultant, officer, or elected or appointed official of the
City, the Subrecipient, or any designated public agency.
28) Procurement Standards and Methods
1) Compliance. The Subrecipient shall comply with current City policy concerning the
purchase of equipment and shall maintain inventory records of all non -expendable
personal property as defined by such policy as may be procured with funds provided
herein. All program assets (unexpended program income, property, equipment, etc.),
shall revert to the City upon termination of this Agreement.
2) OMB Standards. Unless specified otherwise within this agreement, the Subrecipient
shall procure all materials, property, or services in accordance with the requirements of
24 CFR 84.40-48.
3) Travel. The Subrecipient shall obtain written approval from the City for any travel
outside the metropolitan area with funds provided under this agreement.
29) Environmental Issues
1) Air and Water. The Subrecipient agrees to comply with the following requirements
insofar as they apply to the performance of this Agreement:
a) Clean Air Act, 42 U.S.C., 7401, et seq.;
b) Federal Water Pollution Control Act, as amended, 33 U.S.C., 1251, et seq., as
amended, 1318 relating to inspection, monitoring, entry, reports, and information, as
well as other requirements specified in said Section 114 and Section 308, and all
regulations and guidelines issued thereunder;
c) Environmental Protection Agency (EPA) regulations pursuant to 40 CFR Park 50,
as amended.
2) Flood Disaster Protection. In accordance with the requirements of the Flood Disaster
Protection Act of 1973 (42 U.S.C. 4001), the Subrecipient shall assure that for activities
located in an area identified by the Federal Emergency Management Agency (FEMA) as
having special flood hazards, flood insurance under the National Flood Insurance
Program is obtained and maintained as a condition of financial assistance for acquisition
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or construction purposes (including rehabilitation).
3) Lead -Based Paint. The Subrecipient agrees that any construction or rehabilitation of
residential structures with assistance provided under this Agreement shall be subject to
HUD Lead -Base Paint Regulations at 24 CFR 570.608, and 24 CFR Part 35, Subpart B.
Such regulations pertain to all CDBG-assisted housing and require that all owners,
prospective owners, and tenants of properties constructed prior to 1978 be properly
notified that such properties may include lead -based paint. Such notification shall point
out the hazards of lead -based paint and explain the symptoms, treatment and precautions
that should be taken when dealing with lead -based paint poisoning and the advisability
and availability of blood lead level screening for children under seven. The notice
should also point out that if lead -based paint is found on the property, abatement
measures may be undertaken. The regulations further require that, depending on the
amount of Federal funds applied to a property, paint testing, risk assessment, treatment
and/or abatement may be conducted.
4) Historic Preservation. The Subrecipient agrees to comply with the Historic
Preservation requirements set forth in the National Historic Preservation Act of 1966, as
amended (16 U.S.C. 470) and the procedures set forth in 36 CFR Part 800, Advisory
Council on Historic Preservation Procedures for Protection of Historic Properties,
insofar as they apply to the performance of this agreement. In general, this requires
concurrence from the State Historic Preservation Officer for all rehabilitation and
demolition of historic properties that are fifty years old or older or that are included on a
Federal, state, or local historic property list.
30) Notices
Communication and details concerning this contract shall be directed to the following
contract representatives:
City:
Economic Development Department
Attn: CP Coordinator
P.O. Box 190
Huntington Beach, CA 92648
Phone: (714) 536-5542
31) Independent Contractor
Subrecipient:
Community Care Health Centers
Attn: Selina Hudgins
8041 Newman Avenue
Huntington Beach, CA 92647
(714)375-2272
Fax (714) 842-0716
Nothing contained in this Agreement is intended to, or shall be construed in any manner, as
creating or establishing the relationship of employer/employee between the parties. The
Subrecipient shall at all times remain an "independent contractor" with respect to the
services to be performed under this Agreement. The City shall be exempt from payment of
all Unemployment Compensation, FICA, retirement, life and/or medical insurance and
Workers' Compensation Insurance, as the Subrecipient is an independent contractor.
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32) Insurance
General Liability. In addition to the workers' compensation and employer's liability
insurance and Subrecipient's covenant to indemnify City, Subrecipient shall obtain and
furnish to City, a policy of general public liability insurance, including motor vehicle
coverage covering the program / project. This policy shall indemnify Subrecipient, its
officers, employees a.,.d agents while acting within the scope of their duties, against any and
all claims arising out or in connection with the program, and shall provide coverage in not
less than the following amount: combined single limit bodily injury and property damage,
including products/completed operations liability and blanket contractual liability, of One
Million Dollars ($1,000,000) per occurrence. If coverage is provided under a form which
includes a designated general aggregate limit, the aggregate limit must be no less than One
Million Dollars ($1,000,000) for the program / project. This policy shall name City, its
officers, elected or appointed officials, employees, agents, and volunteers as Additional
Insureds, and shall specifically provide that any other insurance coverage which may be
applicable to the program / project shall be deemed excess coverage and that Subrecipient's
insurance shall be primary.
Under no circumstances shall said above -mentioned insurance contain a self -insured
retention, or a "deductible" or any other similar form of limitation on the required coverage.
Workers Compensation and -Employers' Liability. Pursuant to California Labor Code
Section 1861, Subrecipient acknowledges awareness of Section 3700 et seq. of this Code,
which requires every employer to be insured against liability for workers' compensation;
Subrecipient covenants that it will comply with such provisions prior to commencing
performance of the work hereunder.
Subrecipient shall maintain workers' compensation and employer's liability insurance in an
amount of not less than the State statutory limits.
Subrecipient shall require all subcontractors to provide such workers' compensation and
employer's liability insurance for all of the subcontractors' employees. Subrecipient shall
furnish to City a certificate of waiver of subrogation under the terms of the workers'
compensation and employer's liability insurance and Subrecipient shall similarly require all
subcontractors to waive subrogation.
Certificate of Insurance. Prior to commencing performance of the work hereunder,
Subrecipient shall furnish to City certificates of insurance subject to approval of the City
Attorney evidencing the foregoing insurance coverages as required by this Agreement; the
certificates shall:
l . provide the name and policy number of each carrier and policy;
2. state that the policy is currently in force; and
3. promise to provide that such policies will not be canceled or modified
without thirty (30) days' prior written notice of City.
Subrecipient shall maintain the foregoing insurance coverages in force until the work under
this Agreement is fully completed and accepted by City.
The requirement for carrying the foregoing insurance coverages shall not derogate from the
provisions for indemnification of City by Subrecipient under the Agreement. City or its
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representative shall at all times have the right to demand the original or a copy of all the
policies of insurance. Subrecipient shall pay, in a prompt and timely manner, the premiums
on all insurance hereinabove required.
Subrecipient shall provide a separate copy of the additional insured endorsement to each of
Subrecipient's insurance policies, naming City, its officers, elected and appointed officials,
employees, agents and volunteers as Additional Insureds, to the City Attcr—ney for approval
prior to any payment hereunder.
33) Hold Harmless and Indemnity Agreement
Subrecipient hereby agrees to protect, defend, indemnify and hold harmless City, its
officers, elected or appointed officials, employees, agents, and volunteers from and against
any and all, claims, damages, losses, expenses, judgments, demands defense costs, and
consequential damage or liability of any kind or nature, however caused, including those
resulting from death or injury to Subrecipient's employees and damage to Subrecipient's
property, arising directly or indirectly out of the obligations or operations herein undertaken
by Subrecipient, caused in whole or in part by any negligent act or omission of the
Subrecipient, any subcontractors, anyone directly or indirectly employed by any of them or
anyone for whose acts any of them may be liable, including but not limited to concurrent
active or passive negligence, except where caused by the active negligence, sole negligence,
or willful misconduct of the City. Subrecipient will conduct all defense at its sole cost and
expense and City shall approve selection of Subrecipient's counsel. City shall be reimbursed
for all costs and attorney's fees incurred by City in enforcing this obligation. This indemnity
shall apply to all claims and liability regardless of whether any insurance policies are
applicable. The policy limits do not act as a limitation upon the amount of indemnification
to be provided by Subrecipient.
34) Severability
If any provision of this Agreement is held invalid, the remainder of the Agreement shall not
be affected thereby and all other parts of this Agreement shall nevertheless be in full force
and effect.
35) Assignment of Agreement
The Subrecipient shall not assign this Agreement or any monies due thereunder without the
prior written consent of the City.
36) Successors and Assigns
Subject to the provisions of the Subrecipient Agreement Paragraph 16, "Hold Harmless and
Indemnity Agreement," all terms, conditions, and provisions hereof shall inure to and shall
bind each of the parties hereto, and each of their respective heirs, executors, administrators,
successors, and assigns.
37) Section Readings and Subheadings
The section headings and subheadings contained in this Agreement are included for
convenience only and shall not limit or otherwise affect the terms of this Agreement.
07-1221/14243 Page I I of 12
38) Waiver
The City's failure to act with respect to a breach by the Subrecipient does not waive its right
to act with respect to subsequent or similar breaches. The failure of the City to exercise or
enforce any right or provision shall not constitute a waiver of such right or provision.
39) Authority to Execute this Agreement
The person or persons executing this Agreement on behalf of Subrecipient warrants and
represents that he/she has the authority to execute this Agreement on behalf of the
Subrecipient and has the authority to bind Subrecipient to the performance of its obligations
hereunder.
40) Entire Agreement
This agreement constitutes the entire agreement between the City and the Subrecipient for
the use of funds received under this Agreement and it supersedes all prior or
contemporaneous communications and proposals, whether electronic, oral, or written
between the City and the Subrecipient with respect to this Agreement.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed by
and through their authorized officers on W# Y,6M btr S , 2007 .
COMMUNITY CARE HEATH CENTERS
By: 60-1-t� 6MM4�� �-
, print name
I tle one) Chairmareresidentjlice President
AND
By:
u
pre
ITS: (circle on hief Financial Officer/Asst
Secretary - Treasurer
Exhibits:
A. Scope of Work,
B. Subrecipient Budget
CITY OF HUNTINGTON BEACH, a municipal
corporation of the State of California
Director of E omic Development
APPROVED AS TO FORM:
Ci y Attorney,�1 d'I
, C� k01
a1
07-1221/14243 Page 12 of 12
U.S. Department of Housing OMB Approval No. 2506-0117
and Urban Development (Exp. 8/31/2008)
Exhibit A
Scope of Services
Jurisdiction's Name: City of Huntington Beach
Priority Need
Priority Non -Homeless Special Needs
Project Title
Community Care Health Centers
Description
The Community Care Heath Centers (CCHC) Health Care project provides coordinated health services over the
human life cycle. Services are provided directly at Huntington Beach Community Clinic and in multiple areas,
including preventive care, primary care, dental care, mental health, health insurance linkage, women's health
and pediatric care, and pharmaceutical support for Huntington Beach residents. The target population is the
uninsured and medically underserved residents who fall 200 percent below the poverty level.
Objective category: ® Suitable Living Environment ❑ Decent Housing ❑ Economic Opportunity
Outcome category: ® Availability/Accessibility ❑ Affordability ❑ Sustamability
Location/Target Area
Citywide
Objective Number
Project ID
SL-3
2007-7
HUD Matrix Code
CDBG Citation
05M — Health Services
570.201(e)
Type of Recipient
CDBG National Objective
Subrecipient Private
L/M Limited Clientele
570.500(c)
Start Date (mm/dd/yyyy)
Completion Date (mm/dd/yyyy)
10/01/2007
09/30/2008
Performance Indicator
Annual Units
Persons
9,724
Local ID
Units Upon Completion
9,724
Funding Sources:
CDBG $50,000
ESG
HOME
HOPWA
Total Formula
Prior Year Funds
Assisted Housing
PHA
Other Funding
Total $50,000
The primary purpose of the project is to help ❑ the Homeless ❑ Persons with HIV/AIDS ❑ Persons with Disabilities ❑ Public Housing Needs
Exhibit B
Budget
Community Health Care Center
Salaries $50,000
ID P DATE(MM/DD/YYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE OP HUOPI-2 d 05 to 07
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Chapman 6 Associates
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0522024
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 5455
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Pasadena CA 91117-0455
Phone: 626-405-8031 Fax: 626-405-0585
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURER A NORCAL
INSURER B
Community Care Health Centers
Huntington Beach Comm Clinic
8041 Newman Ave.
Huntington Beach CA 92647
INSURERC
INSURER
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
INSK
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
DATE MM/DDFFFC
ICY EXPIRATION
DATE MWDD/YY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
X CLAIMS MADE OCCUR
610352
04/01/07
04/01/08
EACH OCCURRENCE
$ 1000000
PREMISES occuren (Eace)
$ 100000
MED EXP (Any one person)
$ 5000
PERSONAL & ADV INJURY
$ INCL
X
MALPRACTICE
GENERAL AGGREGATE
$ 3000000
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY JEa LOC
PRODUCTS - COMP/OP AGG
$ INCL
Ben.
1000000
A
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
610352
04/01/07
04/01/08
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$ 1000000
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY_ AGG
$
$
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
JENNIF R WG
TH,��Attdmey
5 ' 5167
EACH OCCURRENCE
$
AGGREGATE
$
$
$
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
TORY LIMITS ER
E L EACH ACCIDENT
$
E L DISEASE - EA EMPLOYE
$
E L DISEASE - POLICY LIMIT
1 $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Re: 05/19/07 - 05/20/07 Duck-A-Thon. The City of Huntington Beach, its
Officers, Agents and Employees are named additional insured with respect to
the operations of the named insured per the attached endorsement. 10 days
notice of cancellation for non-payment of premium. XX
CERTIFICATE HOLDER CANCELLATION
CITYOFH I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
DATE THEREOF, THE ISSUING INSURER WILL®MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Huntington Beach
Risk Management Division
2000 Main Street
Huntington Beach CA 92648
/08)
988
Mag 09 20,07 10:03AM COMMUNITY CARE HEALTH CTR 714-842-4353 p.3
Policy Number:
Date Entered 11 / 16 / 2004
ACC. CERTIFICATE OF
LIABILITY INSURANCE
DATE {HMiODiYYYY1
3/@/2aos
PRODUCER Diana R AdMaS In6=Bknc1E Agency
2134 Main St. #290
THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Huntington Heawh, CA 92648
I HOLDER. THIS CERTIFICATE DOES
L ALTER THE COVERAGE AFFORDED
NOT AMEND, EXTEND OR
BY THE POLICIES BELOW.
(714)374-3782
_
INSURED Co®aunity Care Health Centers
4
INSURERS AFFORDING COVERAGE
INSURERA.Mid-Century In=awe Cmp9Tl�'
NAIC S
INSURER B
INSURER C
DSA l•=tington Beach CCmmunLty C'Linic
004L A1sjv/"= Ave.
Huntington Beach, CA 92647
INSURER a
"`-- --------I
IISUFER E
! -----
COVERAGES
THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE: INSUREO 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 TENNIS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE LMAI'rS SHOWN MAY HA✓E BEEN REDUCED BY PAID CLAIMS
AM-
MINI
�, NUMBER
POLICY fFggTNE POLICY EXRRATION
LihET9
GENERAL UASI.ITY
EACH OCCURRENCE
ogwrz T6RENTM e�
"8E8 MA ooemr mw s
r OONMERMI L GENERAL LIABILITY
CUVMB MADE 17 OCCUR
i MEW EXP (Any au psraorQ +f
PERBaM1fAL & AWV IWURY_ T 5 —
1(
i
ceIERAL acoRECATE
1
�
GEN'L AGGREGATE
POLICY
LIMITAPPLIES PER
JECIT FRO- LOC
PRODLC78 OwPkP AGG S
-- ---- —_
AUT
ONCE" LIABILITY
ANY AUTO
T
COUSINED SW L'IIIT f
(Es St,e4�tY
BODIL" INJURY 1 3
(Pof NRoN
I
ALL CVYNED AJTOB
6CkE7ULED AUTOS
I
j
I
8001 LY fWURY
j (FIE swUan; 3
HIRED AUTOS
VON-OMED AJr06
I
PRO—
(Pat �% DAMAGE f
U
!
%%RAGE LIABILITY
AUTC ONLY - EA ACCIDEnT S
N �A" 3
P.AnY Ago
AP OVED S TO�F
RM
EXCn"M5M A LIABILITY
OOCUA ❑ CLAIMS MAAUE i
1E �F�McG,
Ci Attotn�7ey
_
ICI � 0-7
`�
EACH OCCURRENCE 3
AWREaATE S _
f
I ---- 3
DEDUCTIBLE
RETENTION 1
�_
3
WORKERS COMPI NSATION MO
NC: STATU.Y WITS O'N.
ER
A �IDIrw
ar LJAILITr
.NlfPROIRRrOWPARTNERRaECUTNE
O"IOEP MWKA
W446000 weer
AL PROWSICN8 SN®w
A01096132
4/1/2007
I"'---_�
A/l/2006
=.L EACH ACCOENT 3 1 , 000,000
=L OWE _ EA ELSKOYEE f 1, 0 C 0 , 000
. L DBEAM - POLICY LIMIT f 1,000,000
OTHER
OESCRIP'3011 OF OPERATIONS /102AMONS I VEHIMMS I EXCLUBWIJS ADOBD BY 2MODR3EMENT I SPECIAL PROVISION&
SHOULD ANY OF TAB ABOVE DESCRIBED POLICIES BE CANCELLED BEPDaE THE EXPIRATION
DATE THEREOF, THE; RiWWO INSURER IMLL WMEAVOR TO MAIL DAYS WMTTm
NOTICE TO THE CERTIRCATE MOLDER MUM TO THE LEFT, OUT FA{LIM TO OD 80 SHALL
IMPOSE NO OBLIGATION OR UASLM Of ANY KING UPON THE MURER, ITS AaENTB OR
AUTHORI1111) REPRESENTATIVE
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.
25
N �ceCA L
ADDITIONAL INSURED FOR LIMITED PURPOSES -
FUNDING SOURCE
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE DEAD IT CAREFULLY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
PROFESSIONAL LIABILITY COVERAGE FORM
NON -OWNED AND HIRED AUTO COVERAGE FORM
The Persons Insured Sections of the applicable coverage forms are amended to include as Insureds the person(s) and
organization(s) listed below, but only with respect to their liability arising out of the Named Insured's activities within the
scope of funding contracts between the Named Insured and the persons or organizations listed below:
City of Huntington Beach, its Officers, Agents, and Employees; Risk Management Division; 2000 Main Street,
Huntington Beach, CA 92648
No other extension or modification of coverage is expressed, intended or implied by this endorsement.
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED
This endorsement when signed by NORCAL's President and Secretary at San Francisco, California shall take effect on the
endorsement effective date shown below.
Issue Date:
Named Insured:
Policy Number:
Policy Period:
Endorsement Number:
Endorsement Effective Date:
Endorsement Retroactive Date:
May 11, 2007
Community Care Health Centers
610352
April 1, 2007 to April 1, 2008
10
May 10, 2007
May 10, 2007
NCPGAILF (END075) Ed. 4/1/1997 Broker Copy Page i
Policy Number
Date Entered 11/16/2004
ACOR®,M CERTIFICATE OF
LIABILITY INSURANCE
°12/4M/207'
PRODUCER Diane R Adams Insurance Agency
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
2134 Main St. #280
ONLY AND CONFERS NO RIGHTS
UPON THE CERTIFICATE
Huntington Beach, CA 92648
HOLDER. THIS CERTIFICATE DOES
NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED
BY THE POLICIES BELOW.
(714)374-3282
INSURERS AFFORDING COVERAGE
NAIC #
INSURED Community Care Health Centers
INSURER A Mid -Century Insurance Company
INSURER B
INSURER C
DBA Huntington Beach Community Clinic
8041 Newman Ave.
Huntington Beach, CA 92647
INSURER D
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
LTR
ADD'L
INSR
OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
ATE M /D IYY
POLICY EXPIRATION
ATE MMIDD
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
DAMAGE RENTED
COMMERCIAL GENERAL LIABILITY
S 3 (
PREMISEEa occurence)
$
CLAIMS MADE El OCCUR
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER
PRODUCTS - COMP/OP AGG
$
POLICY j RC6 LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
$
AUTO ONLY AGG
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
$
OCCUR F1 CLAIMS MADE
AGGREGATE
$
$
DEDUCTIBLE
$
RETENTION $
STATU- OTH-
WORKERS COMPENSATION AND
TOWC Y LIMITS E
EL EACH ACCIDENT
$ 1,000,000
A
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
01096732
4/l/2007
4/l/2008
EL DISEASE - EA EMPLOYEE
$ 1,000,000
Ifyes, describe under
PROVISIONS below
E L DISEASE - POLICY LIMIT
$
1,000,000SPECIAL
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATF MOI nFR CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Huntington Beach
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
2000 Main Street
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Huntington Beach, CA 92648
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Attn. Risk Management Office
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE Adams
ACORD 26 (2001108) UAGUKU L UKrUKAIKJIV T7aa
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 25 (2001108)
r
From Chapman Cert Request At Chapman Insurance FaxID Chapman Associates To Marilyn Berglund Date 11/7/2007 01 12 PM Page 2 of 6
l6CORD CERTIFICATE OF LIABILITY INSURANCE OP ID P DATE(MM/DDIYYYY)
HU14TI-2 11 07/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. o. Sox 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Pasadena CA 91117-0455
Phone:626-405-8031 Fax:626-405-0585 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER NORICAL
INSURER B
Community Care Health Centers INSURER
8041 Nel iBan Ave. INSURER
Huntington Beach CA 92647
INSURER E
PA
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
INSIR
TYPE OF INSURANCE
POLICY NUMBER
DATE (MMIDONY)
DATE (MMIDDIYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1000000
A
X COMMERCA GENERAL LABILC(Y
610352
04/O1/07
04/O1/08
PREMISEence)
$ 100000
X CLAIMS MADE 7 OCCUR
MED EXP (Any one person)
$ 5000
PERSONAL dADV INJURY
$ 1000000
X Malpractice
GENERAL AGGREGATE
$ 3000000
GEN'LAGGREGATELIMIT APPLIES PER
PRODUCTS - COMP/OPAGG
$ 1000000
X POLICY jEr7 LOC
Mal ract
1000000
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident)
$ 1000000
60DILY IN,LIRY
(Per person)
$
ALL OVvNED AUTOS
SCHEOULEDAUTOS
A
X
X
HIREDAUTOS
NON-OWidED AUTOS
610352
04/01/07
04/01/08
BODILY INJURY
(Per accident)
$
X
Claims Made
PROPERTY DAMAGE
(Per accident)
$
X
Incl . in Agg.
GARAGE LIABILITY
AUTO ONLY - EAACODENT
$
OTHEP THAN EA ACC
$
ANY AUTO
$
AUTO ONLY AGG
EXCESSNMBRELLA LIABILITY
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
$
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
107H-
TLIMITS ER ORT'
E L EACH ACCIDENT
$
E L DISEASE - EA EMPLOYE
$
OFFICERIMEMBER EXCLUDED?
It yes describe under
SPECIAL PROVISIONS below
E L DISEASE - POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
The City of Huntington Beach, subrecipient, its officers, elected or
appointed officials, employees agents and volunteers in respect to the
operations and program/project and shall be deemed excess coverage and
that subrecipient's insurance shall be primary. 30 days notice of
cancellation for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
City of Huntington Beach
Community Development Dept.
2000 Main St.
Huntington Beach CA 92648
CITYOFH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KWD UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
From Chapman Cert Request At Chapman Insurance FaxID Chapman Associates To Manlyn Berglund Date 11r72007 0 12 PM Page 3 of 6
IMPORTA'`.T
If the certificate holder is an ADDITIONAL INSUREr , the policy(les) must be endorsee 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