Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Ferandell Tennis Courts Inc; 2021-04-23; PKRC21-0219
Tracking #: CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 This agreement is made on the :3 day of r , 201, by the City of Carlsbad, California, a municipal corporation, (hereinafter ailed "City"), and Ferandell Tennis Courts Inc. whose principal place of business is 3216 Grey Hawk Ct Carlsbad, CA 92010 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Temujin Matsubara (City Project Manager) PAYMENT. The City shall withhold retention as required by Public Contract Code Section 9203. WAGE RATES. The general prevailing rate of wages for each craft or type of worker needed to execute the Contract shall be those as determined by the Director of Industrial Relations pursuant to Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the applicable wage rates is on file in the Office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777.5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is the City's "duly authorized officer" for the purposes of section 4107 and 4107,5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND FICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 1 of 9 City Attorney Approved 1/22/2020 Tracking #: Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to the City must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and'that eb rm t by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor o om participati in gnjcct bidding. Signature: Print Name: Paul Ferandell, VPres. REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than........$1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than $1,000,000 Property damage insurance in an amount of not less than... $1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 2 of 9 City Attorney Approved 1/22/2020 Tracking #: WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its officers and employees, from all claims, loss, damage, injury and liability of every kind, nature and description, directly or indirectly arising from or in connection with the performance of the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of the City. The expenses of defense include all costs and expenses including attorneys' fees for litigation, arbitration, or other dispute resolution method. JURISDICTION. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Start Work: Contractor agrees to start within 15 working days after receipt of Notice to Proceed. Completion; Contractor agrees to complete work within 46 working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Ferandell Tennis Court Inc. 3216 Grey Hawk Ct (street address) (name of Contractor) 603945 Carlsbad, CA 92010 (Contractor's license number) (city/state/zip) A, B — 10/31/2022 858-350-3444 (license class, and exp. date) (telephone no.) 1000004786 858-350-3488 (DIR registration number) (fax no.) 6/30/2021 manager@ferandelltenniscourts.com (DIR registration exp. date) (e-mail address) III Iii III 11/ /I/ Ill LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 3 of 9 City Attorney Approved 1/22/2020 Ferandell Tennis Courts, Inc. CITY OF CARLSBAD, a municipal corporation of the State of California A fre„City Manager Paul Ferandell, VPrec CELIA A. BREWER, City Attorney BY: Déput9ty Attorney Tracking #: AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. (print name/title) By: (sign here) BARBARA ENGLESON V —City Clerk (print name/title) If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Group Chairman, Secretary, President, or Assistant Secretary, Vice-President CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 4 of 9 City Attorney Approved 1/22/2020 Tracking #: EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). if no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS , — Portion of Project to be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract , 7Nil A Total % Subcontracted: LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS, TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 5 of 9 City Attorney Approved 1/22/2020 Tracking #: EXHIBIT B SCOPE OF WORK Ferandell Tennis Courts will furnish all materials, labor, equipment and services necessary to repair, resurface, and stripe the two (2) tennis courts at La Costa Canyon Park located at 3018 Pueblo St., Carlsbad, CA 92009. The repair and resurfacing to include play area as well as perimeter surfacing. Repair •Waterblast, using a 3500 to 5000 PSI hydroblaster, or diamond grind existing surface to expose all surface spells and pop-outs, clean out existing cracks, and remove any bubbling or peeling of existing surface •Jack hammer out all lifting areas and remove rebar, then patch with Rapid Set Cement All and grind flush with slab •Patch all cracks, visible pop-outs and spalls, using court patch binder and grind or sand flush with slab Resurface •Surface playing area with the "acrylic system" for true ball bounce •Clean and prepare existing surface •Apply acrylic concrete primer to all exposed concrete •Apply one (1) coat of sand-filled acrylic resurfacer, giving surface a smooth, even, and uniform finish •Apply two (2) coats of sand-filled acrylic color for court speed. Match existing color with Acrytech Sports Surfaces; Pro Green (inside) and Classic Red (outside) •Stripe court, utilizing white line primer for sharper edges, as per current USTA specifications •No materials shall be applied if the surface temperature is below 50 degrees Fahrenheit, in excess of 140 degrees Fahrenheit, or when rain or high humidity is imminent •Net posts will be painted green Repair/Resurface $32,800. Continued on next page... LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 6 of 9 City Attorney Approved 1/22/2020 Tracking #: SCOPE OF WORK CONTINUED Ferandell Tennis Courts will furnish all materials, labor, equipment and services necessary to repair, resurface, and stripe the six (6) pickleball courts at Poinsettia Community Park located at 6600 Hidden Valley Rd., Carlsbad, CA 92011. The repair and resurfacing to include play area as well as perimeter surfacing. Repair •Waterblast, using a 3500 to 5000 PSI hydroblaster, or diamond grind existing surface to expose all surface spells and pop-outs, clean out existing cracks, and remove any bubbling or peeling of existing surface •Patch all cracks, visible pop-outs and spalls, using court patch binder and grind or sand flush with slab Resurface •Surface playing area with the "acrylic system" for true ball bounce •Clean and prepare existing surface •Apply acrylic concrete primer to all exposed concrete •Apply one (1) coat of sand-filled acrylic resurfacer, giving surface a smooth, even, and uniform finish •Apply two (2) coats of sand-filled acrylic color for court speed. Match existing color with Acrytech PicklePro Player's Choice; Pro Green (inside), Pro Green (kitchen) and Classic Red (outside) •Stripe court, utilizing white line primer for sharper edges, as per current USTA specifications •No materials shall be applied if the surface temperature is below 50 degrees Fahrenheit, in excess of 140 degrees Fahrenheit, or when rain or high humidity is imminent •Net posts will be painted green Repair/Resurface $27,156. Total amount not to exceed $59,956. LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 7 of 9 City Attorney Approved 1/22/2020 Tracking #: Bond No.: HA 10102445 EXHIBIT C Premium: $1,199.00 LABOR AND MATERIALS BOND WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to Ferandell Tennis Courts, Inc. (hereinafter designated as the "Principal"), a Contract for: LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 in the City of Carlsbad, in strict conformity with the drawings and specifications, and other Contract Documents now on file in the Office of the City Clerk of the City of Carlsbad and all of which are incorporated herein by this reference. WHEREAS, Principal has executed or is about to execute said Contract and the terms thereof require the furnishing of a bond, providing that if Principal or any of its subcontractors shall fail to pay for any materials, provisions, provender or other supplies or teams used in, upon or about the performance of the work agreed to be done, or for any work or labor done thereon of any kind, the Surety on this bond will pay the same to the extent hereinafter set forth. NOW, THEREFORE, WE, Ferandell Tennis Courts, Inc., as Principal, (hereinafter designated as the "Contractor"), and Hudson Insurance Company as Surety, are held firmly bound unto the City of Carlsbad In the sum of fifty-nine thousand nine hundred fifty- six Dollars ($59,956), said sum being an amount equal to: One hundred percent (100%) of the total amount payable under the terms of the Contract by the City of Carlsbad, and for which payment well and truly to be made we bind ourselves, our heirs, executors and administrators, successors, or assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH that if the Contractor or his/her subcontractors fail to pay for any materials, provisions, provender, supplies, or teams used in, upon, for, or about the performance of the work contracted to be done, or for any other work or labor thereon of any kind, consistent with California Civil Code section 9100, or for amounts due under the Unemployment Insurance Code with respect to the work or labor performed under this Contract, or for any amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of the contractor and subcontractors pursuant to section 13020 of the Unemployment Insurance Code with respect to the work and labor, that the Surety will pay for the same, and, also, in case suit is brought upon the bond, reasonable attorney's fees, to be fixed by the court consistent with California Civil Code section 9554. This bond shall inure to the benefit of any of the persons named in California Civil Code section 9100, so as to give a right of action to those persons or their assigns in any suit brought upon the bond. Surety stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the work to be performed hereunder or the specifications accompanying the same shall affect its obligations on this bond, and it does hereby waive notice of any change, extension of time, alterations or addition to the terms of the contract or to the work or to the specifications. LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. I•10. PKRC21-0219 Page 8 of 9 City Attorney Approved 1/22/2020 ndell Ten • Courts Inc. (pri ) name her Tracking #: In the event that Contractor is an individual, it is agreed that the death of any such Contractor shall not exonerate the Surety from its obligations under this bond. Executed by CONTRACTOR this of 1/ffis.r.,e-K_, 20 /. CONTRACTOR: day Executed by SURETY this 25th day of February , 20 21 SURETY: By: (sign here) #fle/— Hudson Insurance Company (name of Surety) 23975 Park Sorrento, Suite #225, Calabasas, CA 91302 (address of Surety) (818)449-3111 (title and organization of signatory) By: (sign here) (telephone number of Surety) (signature ofAttorney-in-Fact) Cyndi Beilman (printed name of Attorney-In-Fact) (attach corporate resolution showing current power of (print name here) attorney) (title and organization of signatory) (Proper notarial acknowledgment of execution by CONTRACTOR and SURETY must be attached.) (President or vice-president and secretary or assistant secretary must sign for corporations. If only one officer signs, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering that officer to bind the corporation.) APPROVED AS TO FORM: CELIA A. BREWER City Attorney By: AssistantS Attorney LA COSTA CANYON AND POINSETTIA COMMUNITY PARKS; TENNIS AND PICKLEBALL COURT RESURFACING; CONT. NO. PKRC21-0219 Page 9 of 9 City Attorney Approved 1/22/2020 (Corporate seal), Attest Dina Daslcalakis Corporate Secretary HUDSON INSURANCE COMPANY By Michael P. Cifone Senior Vice President Bond Number: HA10102445 '114 44 .11 1._JC.)(7)N C e POWER OF ATTORNEY KNOW ALL MIEN BY THESE PRESENTS: That HUDSON INSURANCE COMPANY, a corporation of the State of Delaware, with offices at 100 William Street, New York, New York, 10038, has made, constituted and appointed, and by these presents, does make, constitute and appoint Cyndi Beilman of the state of California its true and lawful Attorney(s)-in-Fact, at New York, New York, each of them alone to have full power to act without the other or others, to make, execute and deliver on its beha1t as Surety, bonds and undertakings given for any and all purposes, also to execute and deliver on its behalf as aforesaid renewals, extensions, agreements, waivers, consents or stipulations relating to such bonds or undertakings provided, however, that no single bond or undertaking shall obligate said Company for any portion of the penal sum thereof in excess of the sum of Fifty-Nine Thousand Nine Hundred and Fifty-Six Dollars and Zero Cents Such bonds and undertakings when duly executed by said Attorney(s)-in-Fact, shall be binding upon said Company as fully and to the same extent as if signed by the President of said Company under its corporate seal attested by its Secretary. In Witness Whereof, HUDSON INSURANCE COMPANY has caused these presents to be of its Senior Vice President thereunto duly authorized, on this 16th day of November , 20 17 at New York, New York. STATE OF NEW YORK COUNTY OF NEW YORK. SS. On the 16th day of November , 20 17 before me personally came Michael P. ifone to me known, who being by me duly sworn did depose and say that he is a Senior Vice President of HUDSON INSURANCE COMPANY, the corporatio4llescribed herein and which executed thc above instrument, that he knows the seal of said Corporation, that the seal affixed to said instrument is such corporate seal, th it was s by order of the Board of Directors of said Corporation, and that he signed his name thereto by like order. PPPPP M. •,,,,,, '• 140 1" • -0 ••••P• Fi 0 • ""••••„ • : : •x STATE OF NEW YORK I t sss"' COUNTY OF NEW YORK • NSW YO II 1- 0•` The undersigned Dina Daskalalcis hereby certifies: That the original resolution, of which the following is a true and correct copy, was duly adopted by unanimous written consent of the Board of Directors of Hudson Insurance Company dated July 27d', 2007, and has not since been revoked, amended or modified: "RESOLVED, that the President, the Executive Vice Presidents, the Senior Vice Presidents and the Vice Presidents shall have the authority and discretion, to appoint such agent or agents, or attorney or attorneys-in-fact, for the purpose of carrying on this Company's surety business, and to empower such agent or agents, or attorney or attorneys-in-fact, to execute and deliver, under this Company's seal or otherwise, bonds obligations, and recognizances, whether made by this Company as surety thereon or otherwise, indemnity contracts, contracts and certificates, and any and all other contracts and undertakings made in the course of this Company's surety business, and renewals, extensions, agreements, waivers, contents or stipulations regarding undertakings so made; and FURTHER RESOVLED, that the signature of any such Officer of the Company and the Company's seal may be affixed by facsimile to any power of attorney or certification given for the execution of any bond, undertaking, recognizance, contract of indemnity or other written obligation in the nature thereof or related thereto, such signature and seal when so used whether heretofore or hereafter, being hereby adopted by the Company as the original signature of such officer and the original seal of the Company, to be valid and binding upon the Company with the same force and effect as though manually affixed." THAT the above and foregoing is a full, true and correct copy of Power of Attorney issued by said Company, and of the whole of the original and that the said Power of Attorney is still in full force and effect and has not been revoked, and furthermore that the Resolution of the Board of Directors, set forth in the said Power of Attorney is now in force. Witness the han,l of the th..inrsigned and the seal of said Corporation this 25 day of ' '20 21 • (Notarial Seal) Notary dblic, State of Ne# York No. 01 6067553 Qualifie irrlIffslirCounty Commission Expires December 10, 202/ CERTIFICATION (Corporate seal) By Dina Daskalakis, Corporate Secretary Anne M. Wright before me, , Notary Public, On 2/25/2021 Date Insert Name of Notary exactly as it appears on the official seal Cyndi Beilman personally appeared CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA County of San Diego Name(s) of Signer(s) Expiration of notary term has been extended by 180 days by CA Executive Orders N-63-20 dated May 7, 2020 and N-71-20 dated June 30, 2020. WAWMPAAPAWWW.WAVAIWWW1aPeoVV.W.Welf,:c ANNE M. WRIGHT COMM. #2201348 cft NOTARY PUBLIC*CALIFORNIA t.r) SAN DIEGO COUNTY _ Commission Expires July 13, 2021 VRAMANWYWAWAWANWWWWWWWWW Place Notary Seal Above who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. Witness my hand and official seal. Signature SignatUre of Notary Public Anne M. Wright OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of the form to another document. Description of Attached Document Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: LI Individual D Individual El Corporate Officer —Title(s): El Corporate Officer —Title(s): 0 Partner 111 Limited 0 General EI Partner El Limited CI General li Attorney in Fact RIGHT THUMBPRINT El Attorney in Fact RIGHT THUMBPRINT LI Trustee OF SIGNER El Trustee OF SIGNER LI Guardian or Conservator Top of thumb here El Guardian or Conservator Top of thumb here El Other: El Other: Signer is Representing: Signer is Representing: A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. ALL PURPOSE ACKNOWLEDGMENT STATE OF CALIFORNIA ) COUNTY OF SAN DIEGO) On Mc) reh Li 20 ,24 before me, KERRY JAY WITKIN, Notary Public, personally appeared PA- t..x_k q.caytct P 11 4----------- -, who proved to me on the basis of satisfactory evidence to be the person(s)-whose name(v) is/arelubscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/herAheirauthorized capacity, and that by his/herhheir- signature0 on the instrument the personK or the entity upon behalf of which the person) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. ,. KERRY JAY VV1TKIN Homey ruitic22.34cAsa 1 .", SAN DIEGO COUNTY ... Comm Exp. APRIL 5, 2022 Signature: Ohlitik.H. (Seal) a t OPTIONAL Description of Attached Document 7‹,(tAk1 L -1-C Title or Type of Document: jyl,,A d_ Number of Pages: -2- Document Date: /14A rc, k 'II 26,7,,/ Notary Contact: 858-756-3350 FERANDELL TENNIS COURTS INC. cinprure; 3216 Grey Hawk CL. Carlsbad CA 92010 • Ph: (858)350-34,14 • Fs: (858) 350-3488 Ins Angeles: 25358 Avenda Ronda, Valawcia CA 91355 • Pk(818) 3834793 • Fx: (58) 350-3488 (800) 900-1344 (.1)ntnitikpr's License 4.60.3945 OIR R wistr.it knY 1001004786 CORPORATE RESOLUTION OF SIGNING AUTHORITY RESOLUTION OF: RESOLVED that the execution of Deeds, powers of attorney, transfers, assignments, contracts, obligations, certificates, and other instruments of whatever nature entered into by the Company directly or through a transfer agent or registrar for any stock company, acting in its capacity as a corporate director or exercising any and all other powers conferred upon it by the letters Patent incorporating it or by the law pertaining to such matters, shall be signed by any one of the persons listed below: Name Title ecimen Signature Paul Ferandell VPres. A( I, Elaine Ferandell the undersigned Pres/Sectv/Treas of Ferandell Tennis Courts, Inc. HEREBY CERTIFY that the foregoing is a true and correct copy of a Resolution of the Board of Directors of said Company passed by a resolution of the said board dated on 12/15/12 and that said Resolution is still in full force and effect. Name: E.Elaine Ferandell Signature • Date: 12/1/2020 PHONE NC, No, Ext): (818) 9334700 so:(818) 9334701 INSURER(S) AFFORDING COVERAGE INSURER A: Berkley Assurance Company INSURER California Automobile Insurance Company INSURER C- : Evanston Insurance Company INSURER : Insurance Company of the West D INSURER E INSURER F: NA1C # 39462 38342 35378 28747 PRODUCER License # OH18131 Momentous Insurance Brokerage, A Marsh & McLennan Agency LLC Company 5990 Sepulveda Blvd., #550 Van Nuys, CA 91411 INSURED Ferandell Tennis Courts, Inc. Paul Ferandell 3216 Grey Hawk Ct. Carlsbad, CA 92010 CONTACT NAME: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORJZED REPRESENTATIVE City of Carlsbad 799 Pine Ave. #200 Carlsbad, CA 92048 FERATEN-01 ROTH A.C'400R CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 2/22/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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). COVERAGES CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADM LTR . TYPE OF INSURANCE INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDDNYYYL POUCY EXP IMM/DDITYYTI LIMITS A ' X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 _, CLAIMS-MADE X OCCUR X VUMB0219970 5/26/2020 5/26/2021 DAMAGE TO RENTED LU S (Ea occone1101_ $ 100,000 MED EXIL(Any one person) $ 10,000 - - ------------------- PERSONAL & ADV INJURY $ 1,000,006 ! GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 2,000,000 POLICY [._).5 i ya ri Lo. .., .... PRODUCTS - COMP/OP AGO $ 2,000,000 OTHER: Deductible $ 2,500 B AuTOMOBILE LIABIUTY _ COMBINED SINGLE LIMIT _(EaAssidant) $ 1,000,000 ANY AUTO BA040000053046 6/512020 6/5/2021 BODILY INJURY (Per person) $ — OWNED — - AUTOS ONLY TC SCHEDULED AUTOS BODILY INJURY_LPer accident) $ X . 1/117eS ONLY ...._ x v osim 11,Ran cEgAlilAMAGE $ C X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE EZXS3025802 5/26/2020 5/26/2021 AGGREGATE $ 2,000,000 DED RETENTION $ D WORKERS COMPENSATION AND EMPLOYERS EMPLOYERS LIABIUTY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE r7 QFFICEPJMEMBER EXCLUDED? N I A (mandatory in NH) .--- -- If yes, describe under DESCRIPTION OF OPERATIONS below VINE 5055562 00 y PER .S.T_AILLTE_ I L ER 5/26/2020 5/26/2021 E.L. EACH ACCIDENT $ 1,000,000 EL. DISEASE - EA EMPLOYEE $ 1,000,000 I EL. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) City of Carlsbad Is named as additional insured. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: VUMB0219970 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract executed prior to the date of occurrence but only to the extent permitted by law and the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Construction project sites at which you performed work for such additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations CG 20 37 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2 0 POLICY NUMBER: VUMB0219970 COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: 1.Only applies to the extent permitted by law; and 2.Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds; the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a.The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b.Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. CG 20 33 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. "Bodily injury" or "property damage" occurring after: a.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C, With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2, Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Business Auto Broadening Endorsement This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I.NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED) II.EMPLOYEES AS INSUREDS III.AUTOMATIC ADDITIONAL INSURED IV.EMPLOYEE HIRED AUTO LIABILITY V.SUPPLEMENTARY PAYMENTS VI.FELLOW EMPLOYEE COVERAGE VII.ADDITIONAL TRANSPORTATION EXPENSE VIII.HIRED AUTO PHYSICAL DAMAGE COVERAGE IX, ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE X.LOAN/LEASE GAP COVERAGE XI.GLASS REPAIR — DEDUCTIBLE WAIVER XII.TWO OR MORE DEDUCTIBLES XIII.AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS XIV.WAIVER OF SUBROGATION XV.UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS XVI.EMPLOYEE HIRED AUTO PHYSICAL DAMAGE XVII.PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT XVIII.HIRED AUTO — COVERAGE TERRITORY XIX.BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 1 of 6 BUSINESS AUTO COVERAGE FORM NEWLY ACQUIRED OR FORMED ENTITY (Broad Form Named Insured) SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: d. Any business entity newly acquired or formed by you during the policy period provided you own 50% or more of the business entity and the business entity is not separately insured for Business Auto Coverage. Coverage is extended up to a maximum of 180 days following acquisition or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. Coverage does not apply to an "accident" which occurred before you acquired or formed the organization. II. EMPLOYEES AS INSUREDS SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: e. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. AUTOMATIC ADDITIONAL INSURED SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: f. Any person or organization that you are required to include as additional insured on the Coverage Form in a written contract or agreement that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. IV. EMPLOYEE HIRED AUTO LIABILITY SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: g. An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. V. SUPPLEMENTARY PAYMENTS SECTION II — LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a. Supplementary Payments, Subparagraphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We are not obligated to furnish these bonds. (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 2 of 6 VI. FELLOW EMPLOYEE COVERAGE: SECTION II — LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee This exclusion does not apply if you have workers' compensation insurance in-force covering all of your "employees". Coverage is excess over any other collectible insurance. VII. ADDITIONAL TRANSPORTATION EXPENSE SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Transportation Expenses, is replaced with the following: We will pay up to $50 per day to a maximum of $1000 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". If your business shown in the Declarations is other than an auto dealership, we will also pay up to $1,000 for reasonable and necessary costs incurred by you to return a stolen covered auto from the place where it is recovered to its usual garaging location. VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, the following is added: c. If Liability Coverage is provided in this policy on a Symbol 1 or a Symbol 8 basis and Comprehensive, Specified Causes of Loss, or Collision coverages are provided under this coverage form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire, subject to the following limit: (1)The most we will pay for "loss" to any hired "auto" is $50,000 or Actual Cash Value or Cost of Repair, whichever is less (2)$500 deductible will apply to any loss under this coverage extension, except that no deductible shall apply to "loss" caused by fire or lightning Subject to the above limit and deductible we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own of similar size and type. This coverage extension is excess coverage over any other collectible insurance. IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a., is amended to add the following: This exclusion does not apply to the accidental discharge of an airbag. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 3 of 6 X. LOAN/LEASE GAP COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added: 4. In the event of a "total loss" to a covered "auto" shown in the schedule or declarations for which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on the lease or loan for that covered "auto," less: a.The amount paid under the Physical Damage Coverage Section of the policy; and b.Any: (1)Overdue lease/loan payments at the time of the "loss"; (2)Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage. (3)Security deposits not returned by the lessor; (4)Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5)Carry-over balances from previous loans or leases. The most we will pay under Auto Loan/Lease Gap Coverage for an insured auto is 25% of the actual cash value of that insured auto at the time of the loss. XI. GLASS REPAIR — DEDUCTIBLE WAIVER SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. XII. TWO OR MORE DEDUCTIBLES SECTION III -PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: If two or more "company" policies or coverage forms apply to the same accident: 1.If the applicable Business Auto deductible is the smallest, it will be waived; or 2.If the applicable Business Auto deductible is not the smallest, it will be reduced by the amount of the smallest deductible; or 3.If the loss involves two or more Business Auto coverage forms or policies the smallest deductible will be waived. For the purpose of this endorsement "company" means the company providing this insurance and any of the affiliated members of the Mercury Insurance Group of companies. XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The requirement in SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit, Or Loss, a., In the event of "accident", you must notify us of an "accident" applies only when the "accident" is known to: (1)You, if you are an individual; (2)A partner, if you are a partnership; (3)A member, if you are a limited liability company; or (4)An executive officer or insurance manager, if you are a corporation. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 4 of 6 XIV. WAIVER OF SUBROGATION SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 5. Transfer of Rights Of Recovery Against Others To Us, section is replaced by the following: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of the operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment, Misrepresentation, or Fraud, the following is added: Any unintentional omission of or error in information given by you, or unintentional failure to disclose all exposures or hazards existing as of the effective date or at any time during the policy period shall not invalidate or adversely affect the coverage for such exposure or hazard or prejudice your rights under this insurance. However, you must report the undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. This provision does not affect our right to collect additional premium or exercise our right of cancellation or non-renewal. XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. For Hired Auto Physical Damage Coverage, is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: 1.Any covered "auto" you lease, hire, rent or borrow; and 2.Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, the following is added and supersedes any provision to the contrary: e. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1)The additional insured is a Named Insured under such other insurance; and (2)You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 5 of 6 XVIII. HIRED AUTO - COVERAGE TERRITORY SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 7. Policy Period, Coverage Territory, e. Anywhere in the world if:, is replaced by the following: e. Anywhere in the world if: (1)A covered "auto" is leased, hired, rented or borrowed without a driver for a period of 30 days or less; and (2)The "insured's" responsibility to pay damages is determined in a "suit" on the merits, in the United States of America, the territories and possessions of the United States of America, Puerto Rico, or Canada or in a settlement we agree to. XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH SECTION V — DEFINITIONS, C. "Bodily Injury" is amended by adding the following: "Bodily injury" also includes mental anguish but only when the mental anguish arises from other bodily injury, sickness, or disease. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 6 of 6 1 29558010000000 27 I DIVIDER PAGE Producer No: 0005473 SAN: Pol Eff Dt: 05-26-2020 Office: Date Printed: 06-01-2020 Time Printed: 11:51:20 Trans Eff Dt: 05-26-2020 Insured Name: FERANDELL TENNIS COURTS Policy No: WVE5055562 Trans Seq No: 003 Trans Type: Change Endorsement Oper Init: AIOPEZ- Company Abbr: IW Release Version: 20.05 User-Selected Sets Copies Printer INSURED COPY 01 PDF ONLY COMPANY COPY 01 PDF ONLY BUREAU COPY 01 PDF ONLY T r- INSURED FERANDELL TENNIS COURTS 3216 GREYBAWX COURT CARLSBAD CA 92010 06-01-20 INSURED Code No. Classifications WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 54 (Ed. 3-08) POLICY INFORMATION PAGE ENDORSEMENT The following item(s) Insured's Name (WC 89 06 01) Policy Number (WC 89 06 02) Effective Date (WC 89 06 03) Expiration Date (WC 89 06 04) Insured's Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer's Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured's Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11) is changed to read: Item 3.B. Limits (WC 89 06 12) Item 3.C. States (WC 89 06 13) Item 3.0. Endorsement Numbers (WC 89 06 14) Item 4. *Class, Rate, Other (WC 89 04 15) Interim Adjustment of Premium (WC 89 04 16) Carrier Servicing Office (WC 89 06 17) Interstate/Intrastate Risk LB. Number (WC 89 06 18) Carrier Number (WC 89 06 19) Issuing Agency/Producer Office Address (WC 89 06 25) X X THE POLICY IS AMENDED AS FOLLOWS: AMENDED TO ADD BLANKET WAIVER OF SUBROGATION *Item 4. Change To: Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remuneration 6,061 Estimated Annual Premium SEE ATTACHED WC 99 06 54 (03-08) EXTENSION Total Estimated Annual Premium Minimum Premium $ 700 Deposit Premium $ 772 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 05-26-20 Policy No.WVE 5055562 00 Endorsement No. 002 Insured FERANDELL TENNIS COURTS Premium: WAIVED UNTIL AUDIT Insurance Company INSURANCE COMPANY OF THE WEST Countersigned By WC 99 06 54 (Ed. 3-08) © 2001 National Council on Compensation Insurance, Inc. INSURED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 0634 (Ed. 8-.00) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). The additional premium for this endorsement shall be 2 % of the total California Workers' Compensation premium otherwise due. Schedule Person or Organization Job Description ANY PERSON / ORG ALL CA OPERATIONS WHEN REQUIRED BY WRITTEN CONTRACT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 05/26/2020 Policy No. WVE 5055562 00 Insured FERANDELL TENNIS COURTS Insurance Company INSURANCE COMPANY OF THE WEST Countersigned By Endorsement No. 002 Premium $ INCL. WC 99 06 34 (Ed. 8-00) INSURED