HomeMy WebLinkAboutINTERVAL HOUSE CRISIS SHELTERS - Subgrantee Agrmt - Community Policing to Combat Domestic Violence Program Funds (federal grant) 10/7/96 - 1996-10-0711
C1
CITY OF HUNTINGTON BEACH
2000 MAIN STREET
HUNTINGTON BEACH CITY HISTORIAN
Alicia M. Wentworth
Retired City Clerk
October 18, 1996
Carol Williams
Interval House Crisis Shelters
Seal Beach, California 90740-2356
Dear Ms. Williams:
CALIFORNIA 92648
The City Council of the City of Huntington Beach at the regular meeting held
October 7, 1996, approved execution of the enclosed subgrantee agreement
between the city and Interval House Crisis Shelters For Community Policing To
Combat Domestic Violence Program Funds for Housing And Community
Development Block Grant funds.
Enclosed is a duly executed copy of the agreement for your records.
Sincerely,
C�v C4
Connie Brockway
City Clerk
CB:jc
Enclosure: Agreement
G:fb11owup:agrmt1tr/Interva1 crisis:jc
Telephone: 714-536-5404
714-842-9825
�8
.r,dd, 11fr
Council/Agency Meeting Held: /o --
c�;
Deferred/Continued to:
Approved ❑ Conditionally Approved ❑ Denied
a
City Clerk's Sign re
Council Meeting Date: October 7, 1996
Department ID Number: PD 96-020
CITY OF HUNTINGTON BEACH
REQUEST FOR COUNCIL ACTION
SUBMITTED TO: HONORABLE MAYOR AND CITY COUNCIL MEMBERS
SUBMITTED BY: MICHAEL T. UBERUAGA, City Administrator
PREPARED BY: RONALD E. LOWENBERG, Chief of Police
SUBJECT: CONTRACTUAL SERVICES FOR DOMESTIC VIOLENCE GRANT
Statement of Issue, Funding Source, Recommended Action, Alternative Action(s), Analysis, Environmkntal Status, Attachment(s)
Statement of Issue:
The purpose of this RCA is approval of contracts with Community Services Program (CSP)
and Interval House for a one year term, October 1, 1996 to September 30, 1997. These
contracts are required for the Federal Domestic Violence Grant that was previously
approved by the Council.
Funding Source:
Federal Citizens Option for Public Safety Program (COPS) Office -Department of Justice
Recommended Action:
Respectfully request,the City Council approve and sign the attached contracts with CSP and
Interval House.
Alternative Action(s):
1. Approve and sign contracts with CSP and Interval House. —
2. Do not approve and sign contracts.
AUEST FOR COUNCIL ACTIA
MEETING DATE: October 7, 1996 DEPARTMENT ID NUMBER: PD 96-020
Analysis:
On August 5, 1996 Resolution #96-64 was passed by the City Council granting approval to
accept Community Policing to Combat Domestic Violence Federal Grant Funds of $198-,505
and to enter into a collaboration with two community based organizations for one year.
Huntington Beach Police Department is to enter into a contractual agreement with the
Interval House Victims of Domestic Violence Shelter and CSP, Inc., Domestic Violence
Assistance Programs. The attached contracts, prepared by the City Attorney's Office, are
for the purposes of this grant.
Environmental Status:
None
Attachment(s):
1. Resolution #96-64
2. Contracts
RCADV.DOC -2- 09/17/96 10:40 AM
•
0
0
SUBGRANTEE AGREEMENT BETWEEN THE CITY OF
HUNTINGTON BEACH AND INTERVAL HOUSE CRISIS SHELTERS
FOR COMMUNITY POLICING TO COMBAT DOMESTIC
VIOLENCE PROGRAM FUNDS
THIS AGREEMENT is entered into this ' "' day of , 1996, between
the CITY OF HUNTINGTON BEACH, a municipal corporation of the State of California,
hereinafter referred to as "CITY," as an entitlement recipient in the U. S. Department of Justice,
Office of Community Oriented Policing Services, and Interval House Crisis Shelters, a nonprofit
California corporation, hereinafter referred to as "SUBGRANTEE," for the expenditure of
Community Policing to Combat Domestic Violence Program (CPCDVP) funds;
The Community Policing to Combat Domestic Violence Program, hereinafter referred to
as "CPCDVP," mandates that a Subgrantee Agreement be executed in order that such funds be
utilized by the parties hereto.
IT IS HEREBY AGREED that the following provisions are approved and shall constitute
the entire agreement between the CITY and SUBGRANTEE:
The purpose granting $86,680 in CPCDVP, funds to SUBGRANTEE shall be
solely for domestic violence sheltering services, training and resources for the Huntington Beach
Police Department officers.
a. SUBGRANTEE shall provide training and resources for the officers of the
Huntington Beach Police Department in the area of domestic violence. In addition,
SUBGRANTEE shall provide counseling, advocacy, shelter, outreach counseling, legal
counseling, and comprehensive support services to victims of domestic violence with whom the
Huntington Beach Police Department has contact. Such services will be offered in English,
Spanish, Vietnamese, and such other languages as necessary.
WPUG:AgreeAnterval
RLs 96-518
CPCDVP funds shall be expended within a time period not exceeding twelve (12)
consecutive months, Oct, 1, 1996 through Sept. _ 30, 1997, following the date of
execution of this agreement, in installments determined by CITY. Disbursements shall be made to
SUBGRANTEE following the submission of invoices in a form prescribed by CITY, detailing
such expenses. SUBGRANTEE agrees to submit requests for disbursement fifteen (15) days
after the end of each period which are:
a. September 1, 1996 through November 1996;
b. December 1; 1996 through February 1997;
C. March 1, 1997 through May 1997;
& June 1, 1997 through August 31, 1997.
CITY shall disburse funds based upon the submittal of such invoices within thirty (30)
days after receipt thereof, provided CITY is satisfied that such expenses have been incurred within
the scope of this Agreement and that SUBGRANTEE is in compliance with the terms and
conditions of this Agreement. City has the right to recapture all or a portion of CPCDVP funds
not requested for disbursement 30 days after the end of the fiscal year, June 30, 1996.
2. SUBGRANTEE agrees to conduct all activities of the organization, whether
funded in whole or in part by CPCDVP funds from CITY, in accordance with the provisions
contained in the Federal Office of Management and Budget ("OMB") Circular A-87 and its
attachments, including those for contracts in excess -of Ten Thousand Dollars ($10,000.00) and
including the provisions relating to audit requirements and resolution of audit findings as provided
in Circular A-128. SUBGRANTEES who have received $25,000 or more in grant funds are
required to submit an annual report including either a single audit or program audit reports, which
evidence an audit was completed in accordance with specific program requirements of the OMB
Circular (i.e., A-128 or A-133).
2
WPL:G:AgrecAnterval
RLS 96-518
•
•
3. The CITY shall have the right to recapture all or a portion of CPCDVP funds
disbursed to SUBGRANTEE should the SUBGRANTEE fail to comply with all of the terms and
conditions of this agreement or refuse to accept any conditions which may subsequently be
imposed by the U. S. Department of Justice for the operation of the Community Policing to
Combat Domestic Violence Program.
4. SUBGRANTEE shall not dispose of any real or personal property acquired in full
or in part with CPCDVP funds through sale, use, or relocation without the express and prior
written permission of the City, and SUBGRANTEE agrees to maintain program records for a
minimum of three years after the close-out of the subgrant and to make such records available for
onsite monitoring by CITY not less than annually and to periodic inspections by HUD officials
during this three-year period.
SUBGRANTEE agrees that no officer, employee, agent, or assignee of CITY
having direct or indirect control of CPCDVP funds granted to the CITY shall serve as an officer
of SUBGRANTEE. Further, any conflict or potential conflict of interest of any officer of
SUBGRANTEE shall be fully disclosed to the City prior to the execution of this agreement and
shall be attached to and become a part hereof.
6. SUBGRANTEE agrees that any earned interest income on funds generated
through the use or investment of funds received from CITY shall be used in conformance with
program income requirements set forth in Code of Federal Regulations 570.504. The
SUBGRANTEE shall disclose to the CITY all program income received utilizing CPCDVP funds
administered under this Agreement.
3
7/PL:G:Agree:Interva1
RLs 96-518
7. SUBGRANTEE agrees that in the event it is unable to perform or defaults upon
any provision contained herein, the CITY shall have the right to recapture the full amount of
funds granted to SUBGRANTEE.
',8. SUBGRANTEE acknowledges that the CITY shall disburse funds to
SUBGRANTEE only upon execution of this agreement, and CITY is empowered only to provide
funds to SUBGRANTEE pursuant to the provisions of this agreement.
9. SUBGRANTEE hereby agrees to protect, defend, indemnify and hold and save
harmless CITY, its officers, and employees against any and all liability, claims, judgments, costs
and demands, however caused, including those resulting from death or injury to
SUBGRANTEE'S employees and damage to SUBGRANTEE'S property, arising directly or
indirectly out of the obligations or operations herein undertaken by SUBGRANTEE, including
those arising from the concurrent negligence of CITY, but save and except those which arise out
of the sole negligence, or the sole willful misconduct of CITY. SUBGRANTEE will conduct all
defense at its sole cost and expense. CITY shall be reimbursed by SUBGRANTEE for all costs
or attorney's fees incurred by CITY in enforcing this obligation.
10. WORKERS COMPENSATION INSURANCE. Pursuant to California Labor
Code Section §1861, SUBGRANTEE acknowledges awareness of Section 3700 et seq. of said
code, which requires every employer to be insured against liability for workers' compensation;
SUBGRANTEE convenants that it will comply with such provisions prior to commencing
performance of the work hereunder.
SUBGRANTEE shall maintain such workers compensation insurance in an amount of not
less than One Hundred Thousand dollars ($100,000) bodily injury by accident, each occurrence,
One Hundred Thousand Dollars ($100,000) bodily injury by disease, each employee, and Two
4
7/PL:G:Agree:1nterva1
RLS 96-518
•
•
Hundred Fifty Thousand Dollars ($250,000) bodily injury by disease, policy limit, at all times
incident hereto, in forms and underwritten by insurance companies satisfactory to CITY.
SUBGRANTEE shall require all subcontractors to provide such workers' compensation
insurance for all of the subcontractors' employees. SUBGRANTEE shall furnish to CITY a
certificate of waiver of subrogation under the terms of the worker's compensation insurance and
SUBGRANTEE shall similarly require all subcontractors to waive subrogation.
11. INSURANCE. In addition to the workers compensation insurance and
SUBGRANTEE's covenant to indemnify CITY, SUBGRANTEE shall obtain and furnish to
CITY, a policy of general public liability insurance, including motor vehicle coverage covering the
PROJECT. Said policy shall indemnify SUBGRANTEE, its officers, agents and employees, while
acting within the scope of their duties, against any and all claims of arising out of or in connection
with the PROJECT, 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 $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
$1,000,000. Said policy shall name CITY, its officers, and employees as Additional Insureds, and
shall specifically provide that any other insurance coverage which may be applicable to the
PROJECT shall be deemed excess coverage and that SUBGRANTEE's insurance shall be
primary.
Under no circumstances shall said abovementioned insurance contain a self -insured
retention, or a "deductible" or any other similar form of limitation on the required coverage:
12. CERTIFICATES OF INSURANCE; ADDITIONAL INSURED
ENDORSEMENTS. Prior to commencing performance of the work hereunder, SUBGRANTEE
5
WPL:G:Agree:Interval
RLs 96-318
shall furnish to CITY certificates of insurance subject to approval of the City Attorney evidencing
the foregoing insurance coverages as required by this Agreement; said certificates shall:
1. provide the name and policy number of each carrier and policy;
`2. shall state that the policy is currently in force;
3. shall promise to provide that such policies will not be canceled or modified without
thirty (30) days prior written notice of CITY; and
4. shall state as follows: "The above detailed coverage is not subject to any
deductible or self -insured retention, or any other form of similar type
limitation. "
SUBGRANTEE 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 SUBGRANTEE under the Agreement. CITY
or its representative shall at all times have the right to demand the original or a copy of all said
policies of insurance. SUBGRANTEE shall pay, in a prompt and timely manner, the premiums on,
all insurance hereinabove required.
A separate copy of the additional insured endorsement to each of
SUBGRANTEE's insurance policies, naming the CITY, its officers and employees as Additional
Insureds shall be provided to the City Attorney for approval prior to any payment hereunder.
13. CALIFORNIA FAIR EMPLOYMENT AND HOUSING ACT. SUBGRANTEE
agrees to comply with all requirements and utilize fair employment practices in accordance with
the California Government Code sections 12900 et seq.
6
7/PL: G : Agre a Jnterva1
RLS 96-518
14. CALIFORNIA PREVAILING WAGE LAW. The CITY has ascertained from the
Director of Industrial Relations of the State of California the general prevailing rate of per diem
wages and the general prevailing rate for legal holiday and overtime work in the locality in which
the works is to be performed for each craft or type of work needed to execute this Agreement,
and the same has been set forth by resolution on file in the office of the City Clerk of CITY.
SUBGRANTEE and any subcontractor under it shall pay not less than said prevailing wage rates
to all workers employed on this Subgrantee Agreement, as required by California Labor Code
Sections 1771 and 1774. In accordance with the provisions of Section 3700 SUBGRANTEE
agrees to secure payment of compensation to every employee.
15. CALIFORNIA PREVAILING WAGE LAW - PENALTY. Pursuant to this
Agreement and in accordance with section 1774 and 1775 of the California Labor Code,
SUBGRANTEE shall, a penalty to CITY, forfeit twenty-five dollars ($25) for each calendar day
or portion thereof for each worker paid (either by SUBGRANTEE or any of its subcontractors)
less than the prevailing wage rate established for that particular craft or type of work.
16. CALIFORNIA EIGHT -HOUR LAW. California Labor Code, Section 1810 et
seq., shall apply to the performance of this Agreement; thereunder, not more than eight (8) hours
shall constitute one day's work and SUBGRANTEE and each subcontractor employed by its
hereunder, shall not require more than eight (8) hours of labor per day or forty (40) hours per
week from any one person employed by it hereunder, except as stipulated in California Labor
Code, Section 1815. SUBGRANTEE and each subcontractor employed by it hereunder shall, in
accordance with Section 1812, keep an accurate record, open to inspection at all reasonable
hours, showing the name and actual hours worked each calendar day and each calendar week by
each worker employed in connection with the PROJECT.
7
7MUG:AgreeAnterval
RLs 96-518
17. CALIFORNIA EIGHT HOUR LAW - PENALTY. Pursuant to this Agreement
and in accordance with California Labor Code Section 1813, SUBGRANTEE shall, as a penalty
to CITY, forfeit twenty-five dollars ($25) for each worker employed hereunder by
SUBGRANTEE or any subcontractor for each calendar day during which such worker is required
or permitted to work more than eight (8) hours in any one (1) calendar day or forty (40) hours in
any one (1) calendar week in violation of California Labor Code Section 1815.
18. PAYMENT OF TRAVEL AND SUBSISTENCE ALLOWANCE. Section
1773.8 of the California Labor Code, regarding the employment of apprentices, is applicable to
this PROJECT.
19. EM[PLOYMENT OF APPRENTICES. Section 1777.5 of the California Labor
Code, regarding the employment of apprentices, is applicable to this paragraph.
20. PAYROLL RECORDS. SUBGRANTEE agrees to keep accurate payroll record
showing the name, address, social security number, work classification, straight time and overtime
hours'worked each day and week, and the actual per diem wages paid to each journeyman,
apprentice or worker employed by it in connection with the project and agrees to require each of
its subcontractors to do the same. SUBGRANTEE further agrees that its payroll records and
those of its subcontractors, if any, shall be available at all reasonable times to the CITY, and the
employee or his representative, and the Division of Labor Standards Enforcement and the
Division of Apprenticeship Standards, and to comply with all of the provisions of California
Labor Code Section.1776, in general.
21. INDEPENDENT CONTRACTOR. It is understood and agreed that the
SUBGRANTEE is, and shall be, acting at all times hereunder as an independent contractor and
not as an employee of CITY. SUBGRANTEE shall secure, at its expense, and be responsible for
8
WPUG:Agree:Interval
RLS 96-518
I�
•
any and all payment of income tax, social security, state disability insurance compensation,
unemployment compensation and other payroll deductions for SUBGRANTEE and its officers,
agents and employees, and all business licenses, if any, in connection with the project.
22. All notices pertaining to this Agreement, and any communications from the parties
may be made by delivery of said notices in person or by depositing said notices in the U.S. Mail,
registered or certified mail, return, receipt requested, postage prepaid and addressed as follows:
To CITY:
City of Huntington Beach
Police Department
2000 Main Street
Huntington Beach, CA 92648
Attention: R. E. L.owenberg
To SUBGRANTEE:
Interval House Crisis Shelters
P.O. Box 3356
Seal Beach, CA. 90740-2356
Attention: Carol Williams
Any of the parties may cancel this Agreement by giving thirty (30) days written notice of
said cancellation to the other party hereto. In the event of termination or cancellation for any
reason, CITY shall be liable for services rendered up to such termination.
This document fully expresses all understandings of the parties concerning all matters
covered and shall constitute the total Agreement. No prior written or oral provisions or
understanding, between the parties shall have any force or affect. No addition to or alteration of
the terms of this Agreement shall be valid unless made in writing and formally adopted in the same
manner as this Agreement.
23. SIGNATURES/TIlVIE OF EXECUTION, This agreement shall be void and its
terms shall have no force or effect whatsoever if not signed by authorized agents or officers of
SUBGRANTEE within thirty (30) days of receipt of this document. It shall be the responsibility
E
7/PL:G:Agme:1nterva1
RLs 96-518
•
of the City to transmit this agreement and any other necessary documentation to SUBGRANTEE
and to record the date of receipt thereof.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
by and -through their authorized officers the day, month and year first above written.
INTERVAL HOUSE CRISIS SHELTERS CITY OF HUNTINGTON BEACH, A
a nonprofit California corporation municipal corporation of the State of
/ California
By:
o �T rr► S6tr,
print name Mayor
ITS: (circle one) .Chairm residen • ice
President ATTEST:,
By-6',E 0 R W 1 �. L
ri n me -
ITS: (circ one) Secreta of Financial
Officer/Asst. Secretary Treasurer
weZ
City Clerk
APPROVED TOFORM:
Fity •
...1,1,�"I
0
10
of Police
7/PL:G:Agree:1nterva1
RLS 96-518
•
•
RESOLUTION NO. 96-64
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
HUNTINGTON BEACH AUTHORIZING PARTICIPATION IN
COMMUNITY POLICING TO COMBAT DOMESTIC VIOLENCE
FEDERAL GRANT PROGRAM
'•WHEREAS, the City Council of the City of Huntington Beach desires to participate in
the federal Community Oriented Policing Services (COPS), Community Policing to Combat
Domestic Violence grant program administered by the COPS office;
BE IT RESOLVED that Ronald Lowenberg, Chief of Police of the City of Huntington
Beach, is authorized on its behalf to execute the Community Policing to Combat Domestic
Violence grant award agreement including any extensions or amendments thereof;
BE IT FURTHER RESOLVED that the City of Huntington Beach agrees to enter into a
collaboration with CPS, Inc., and the Interval House Domestic Violence Victims Shelter to
provide assistance to victims of domestic violence.
BE IT FURTHER RESOLVED that the City of Huntington Beach agrees to act as the
host agency and provide required grant administration and financial audit requirements of the
grant program which is entitled "Huntington Beach Collaboration Against Domestic Violence."
PASSED AND ADOPTED by the City Council of the City of Huntington Beach at a
regular meeting thereof held on the 5th day of August , 1996.
Mayor
ATTEST:
City Clerk
---�
/� ✓!-lie
WIN. •
APPROVE9 AS TO FORM:
�i_� ity Attorney
I/NITT � D AND
JAPP(RO
l'/ a 7, JI.
ice Chie
impil(Molence/7/24/96
•
�J
FROM : INTERVAL HOUSESYSTEMI • ,PHONE NO.
• Sep. 12 1996 01:09PM P2
Sep 12.96 10.45 No.010 P.01
Chappmull & ASSDCI$tes be
361 North Sam Gabriel Blvd.
PUMMo CA 91107
Do A� Agricultural Imourafte
INS
Interval House DO D 0°"'a"''
P,.0. Box 3356 CC OO 0
Seal Beach, CA 90740
` C rlaF �pAW
THI.31S TO 6c.nTiry Tf IAT THE POLICIES OP INSURAME L16TID BELOW HAVE OUN 168UED TO IK 1NBURED NAMED A
INDICATED, NOi1NITMSYANDINA ANY REOUi UIREMENT, TEM OR CONDITION OR ANY CONTRACTOR MEA DOOUMiNT'
CEFIIIRIOATE MAY BE INUED OR MAY PERTAIN, THE INSURA1406 WORDED 13Y TH9 POLICIES 02SOMBEC HEREIN FE
04U ONs AND OONDIT s OFWOH POLIC , LIMIT 6HOWN MAY HAVE EEN SD B PAID OLAIMF3.
& TYPE OPImmRANOE POUOY NNNBE" POL ov woE wis P1buby t mAmm
DAU GOWN" DATFdtItlAOwni.
A eerleeAL umury IPAC720686103 10/30/93 10/30/% COMM
N
OOMMF DIAL WNE L L" L{TY
4LAIM19 MANJ ODOUA P
OWNER'S A OONTRAMM S PRAT COOL
SW PTnfesslenal I F AI
MOW M
A AU 0WOUSUABIUN
I THE POLICY PFF1100
Rmy TO wmmi We
' 10 ALL TKII TA,119,
WtlTPI
ANY AUTO
PAC720696103
10/30195
10130196
OWSINID $IN" LIMIT
f 1,ppp1000
FfbOp.V DNURY
(Pa RNafON
ALL OWNED AUT09
amm uI o once
moarDw AY
i
3`
WM AUTW
Na auras
AFPI?i)ti �ri
FOB
�.
PROPeRTYDAMAN
a
OAAMIUMUTY
tLM_ OW - EA
>t
OTHROTHM,% ONLY,
•
ANY AU1O
BY
rne31
EIa uAmUrf BmC6 a__. �. _....[
UrlP+rls .4 FORM OAEOA
ELLA PORN
YMRtOYIG 00MIARL MM AND r
wiff
ELEAW-bbtORT b
TN" PROPRVMPU i', '� • J
RA�'IMIER81�%[;4NTPvE . _ � `V-:`;�;. r OPfi6AaR+ROLE4YL41�' a
'MRS ARH: EL DI8EA9E- all E 3
OT49A 1h�!ti
y � !
pE8CA1R11Q OPERATfb1�A.00AtICnBtYEJ11CtEPABPgdA41reM6 1
Certificate holder is named as additional inSUred as ftiO cts their
lntemarin connection with the rammed Insured
MINOR IN III,
DRMD ANY OF TIE ABOYS DROGI M PWO95 U QUIN ED UPON TNa
City of Ifuntingtnn Beach FJ PIMT10m DATE thomr, 114 "UIN0 6ONPANY WILT. MENWOMo MOL
it' a 6014*r4 agents and DAYS vimmN mmm TO Ta OERnmcATa motor moo -ro %K LEPT, ff
employe"31
I
2l100 Main st"Ot W 1 0I
Hlllttm&nBeach►CA PU48 T
A
% x., � y .U.�EtLr.�,J it �49r R X j.. it t cn �-',..W '�1.;. fk�.�.J. r ',r rn; 1YJ i t-'»'.-i 'i°jk Zk �.,,; nK r k.•a� Mw• S.. r :�r ��
�`;:�i�.,�,S..w.Jicv«..w.�..i:.issw�.�,.,. .r �.a......7�...v.�w:J:>:II..J, '".11...J!•YY.Nw.v.6•.v;1.M�.�1.1I.J.rw.+n.w....�:h;�,-rILr1..,... J.•...t:Y ''11...J,...-.:v�.«io ..m?.Y.� c .w.. .; 1 lY 1 11
FROM INTERUAL. HOUSESYSTEM • PHONE NO.
TEL
i
12 1996 01:10PM P3
Sep 12,96 t45 No:010. P.02
POLICY NUMBER: PAC720686103 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REACT IT CAREFULLY.
ADDITIONAL INSUREDD----DESIGNATED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the foliowft
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
$C: iDULE
ROM$ of Pat1" Or &2601101119nt
City of Huntington Beach,
Is agents, officers, and employees
0 Main Street
Huntington Beach, CA 92648
attn: Sgt. Ran Burgess
i
(V no entry appears above. Inbrmation required to complete thk endorsement wilt be ShOWn In the Oeclamtiona
as appaeebte to this endorsement.)
WHO IS AN INSURED (Section 11) is arnende4 to include 86 an Irrtured the person or 4rgpnintlon shown in the
Schedule as an insured but only with respect to liability arising owt Of your operations of ptemisas owned by or
rented to you.
Interval House
P.O. Box 3356
Seal Beach, CA 90740
C141so 26ites,
R=91% r
CoPyriSht. Inrx*nc a jorvices Oltlto. Ine.,1084
0
09 i12-96 01:08PM P603 #35
JANUARY 12, 1996
POLICY NO. 594090-96
EAP $15,012
SG REP 04
INTERVAL HOUSE
P 0 BOX 3356
SEAL BEACH, CALIF 90740
Dear Policyholder,
Thank you for renewing your workers' compensation coverage with State Fund.
Enclosed is your State Fund Workers' Compensation and Employer's Liability Insurance
Policy, Form L, along with the endorsements appropriate to your policy and a number
of inserts.
The policy language incorporates the changes required by the Reform Act of 1-993 and
the language of endorsements issued to you over the past few years. It continues to
provide full coverage for your California workers' compensation liability. You will also
find endorsements specific to your policy enclosed. Please review them along with the
policy to make sure the coverage meets your current workers' compensation insurance
needs. If any changes are necessary, contact your local district office. The address and
phone number are below.
Your Employer's Liability limit is $1 million including defense costs.
There are three inserts included in this package. The first two inserts are required
policyholder -notices. One explains the new California workers' compensation rating law
applicable to policies with anniversary dates on or after January 1, 1995. The other
describes the available State Fund loss control consultation services. The third insert,
"Understanding Your Declarations Page," illustrates how to read your Declarations Page
and how to determine your rate.
If you have any questions on the policy contract or the impact of competitive rating on
your policy, again, please contact your local district office. The staff will answer your
questions and make any changes necessary for you.
SOUTH ORANGE
3150 BRISTOL ST.
COSTA MESA, CA 92626
TELEPHONE NO. (714) 668-3445
Thank you for letting us continue to serve your workers' compensation needs. We, at
State Fund, value your business with us.
,IMPORTANT - T S NOT A BILL. SEND NO MONEY UNLESS STATEN
IE&T IS ENCLOSED.
STATE HOME OFFICE SAN FRANCISCO POLW DECLARATIONS
COMPENSATION
INSURANCE CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY
FUND THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON.
THIS INSURANCE IS EFFECTIVE FROM
12:01 A.M., PACIFIC STANDARD TIME / CONTINUOUS POLICY 594090-96
2-01-96 TO 2-01-97 AND SHALL
AUTOMATICALLY RENEW EACH 2-01
UN
TIL CANCELLED
INTERVAL .HOUSE DEPOSIT PREMIUM
P 0 BOX 3356
SEAL BEACH, CALIF 90740 MINIMUM PREMIUM
PREMIUM ADJUSTMENT PERIOD
REP 04
NAME OF EMPLOYER- INTERVAL HOUSE
(A NON-PROFIT CORP.)
(A NON-PROFIT CORP.)
LOCATIONS- 14921 MONROE, MIDWAY CITY 92655
200 MARINA DR #2, SEAL BEACH 90740
$3,118.00
$200.00
MONTHLY
R SG
1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE
WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA.
2. EMFLOYER'S LIABILITY INSURANCE - NART TWO OF THIS POLICY APPLIES TO
LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR
LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS,
$1,000,000
CODE NO. PRINCIPAL WORK AND RATES.EFFECTIVE TO 27-01-97
INTERIM
BASE BILLING
RATE RATE*
8810 CLERICAL OFFICE EMPLOYEES--N.O.C. 1.03 .79
8804 ALCOHOLIC AND DRUG RECOVERY HOMES --ALL 6.79 5.23
EMPLOYEES--N.P.D. WITH 9070(1),
"RESIDENTIAL CARE FACILITIES FOR THE
ELDERLY", 9070(3), "RESIDENTIAL CARE
FACILITIES FOR ADULTS", 8823, "RESIDEN-
TIAL CARE FACILITIES FOR CHILDREN", OR
8851, "CONGREGATE LIVING FACILITIES FOR
THE ELDERLY"
EXPERIENCE MODIFICATION
2-01-96 TO 2-01-97 80
ON THE EFFECTIVE DATE SHOWN ABOVE, THE COVERAGE PROVIDED BY
THIS POLICY REPLACES ALL PRIOR COVERAGE.
COUNTERSIGNED XND ISSUED AT SAN FRANCISCO JANUARY 12, 1996 POLICY FORM L 1
� .. (nVER PLEASE)
IMPORTANT - &IS NOT A BILL. SEND NO MONEY UNLESS STATEWT IS ENCLOSED.
STATE HOME OFFICE SAN FRANCISCO T POM DECLARATIONS
N S U R A N'C E CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY
FUND THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON.
PAGE 2
CONTINUOUS POLICY 594090-96
********BUREAU NOTE INFORMATION'"'°''"'"`***
2-07-73-43
COUNTERSIGNED XMD ISSUED AT SAN FRANCISCO JANUARY 12, 1996 POLICY FORM L 2
InVFR PI FASEI __
IMPORTANT - - IS NOT A BILL. SEND NO MONEY UNLESS STATEANNT IS ENCLOSED.
STATE
HOME OFFICE SAN FRANCISCO
POLW DECLARATIONS
COMPENSAT
II N S U R A NIC E
CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY
FUND
THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON.
PAGE 3
CONTINUOUS POLICY 594090-96
INTERIM BILLING RATES WILL BE USED ON PAYROLL REPORTS. THEY TAKE INTO ACCOUNT
RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN
ESTIMATE OF YOUR PREMIUM DISCOUNT AS DETAILED BELOW.
RATING PLAN CREDITS (DEBITS) EFFECTIVE AS OF 02-01-96
ESTIMATED PREMIUM DISCOUNT
THIS ESTIMATED DISCOUNT IS BASED ON AN ESTIMATE
OF YOUR PAYROLL. THE ACTUAL DISCOUNT APPLIED
AT FINAL BILLING WILL BE BASED ON THE ACTUAL
PAYROLL REPORTED ON YOUR POLICY AND SUBJECT TO
AUDIT. SEE PREMIUM DISCOUNT TABLE BELOW.
COMPOSITE FACTOR APPLIED TO BASE RATES TO DERIVE
INTERIM BILLING RATES
INTERIM
BILLING
FACTOR
—23% 0.77
0.77
PREMIUM DISCOUNT
YOUR ESTIMATED STANDARD PREMIUM IS $ 10726.
STANDARD PREMIUM IS DISCOUNTED ACCORDING TO THE FOLLOWING SCHEDULE:
FIRST NEXT ABOVE
$1,000 $4,000 $5,000 'Y
* 0.0% 21.8% 27.2%
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO JANUARY 12, 1996 POLICY FORM L 3L
rnvro of cAccl