Loading...
HomeMy WebLinkAboutVince Dixon Ford Inc dba Ken Grody Ford; 2023-05-15; PSA23-2176FLTPSA23-2176FLT City Attorney Approved Version 12/28/2022 1 AGREEMENT FOR A489 TRANSMISSION REPLACEMENT SERVICES KEN GRODY FORD THIS AGREEMENT is made and entered into as of the ________ day of _________________________, 2023, by and between the City of Carlsbad, California, a municipal corporation ("City") and Vince Dixon Ford, Inc., a California corporation d.b.a. Ken Grody Ford ("Contractor”). RECITALS City requires the services of a transmission replacement consultant that is experienced in transmission replacement. Contractor has the necessary experience in providing these services, has submitted a proposal to City and has affirmed its willingness and ability to perform such work. NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, City and Contractor agree as follows: 1.SCOPE OF WORK City retains Contractor to perform, and Contractor agrees to render, those services (the “Services”) that are defined in Exhibit “A,” attached and incorporated by this reference in accordance with the terms and conditions set forth in this Agreement. 2.TERM This Agreement will be effective for a period of one (1) year from the date first above written. 3.COMPENSATION The total fee payable for the Services to be performed will be seven thousand five hundred sixty- eight dollars and seventy-one cents ($7,568.71). No other compensation for the Services will be allowed except for items covered by subsequent amendments to this Agreement. City reserves the right to withhold a ten percent (10%) retention until City has accepted the work and/or the Services specified in Exhibit “A.” 4.STATUS OF CONTRACTOR Contractor will perform the Services as an independent contractor and in pursuit of Contractor’s independent calling, and not as an employee of City. Contractor will be under the control of City only as to the results to be accomplished. 5.INDEMNIFICATION Contractor agrees to indemnify and hold harmless the City and its officers, officials, employees and volunteers from and against all claims, damages, losses and expenses including attorney’s fees arising out of the performance of the work described herein caused by any negligence, recklessness, or willful misconduct of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable. The parties expressly agree that any payment, attorney’s fee, costs or expense City incurs or makes to or on behalf of an injured employee under the City’s self-administered workers’ compensation is included as a loss, expense or cost for the purposes of this section, and that this section will survive the expiration or early termination of this Agreement. DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C May 15th PSA23-2176FLT City Attorney Approved Version 12/28/2022 2 6. INSURANCE Contractor will obtain and maintain policies of commercial general liability insurance, automobile liability insurance, a combined policy of workers' compensation, employers liability insurance, and professional liability insurance from an insurance company authorized to transact the business of insurance in the State of California which has 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, in an amount of not less than one million dollars ($1,000,000) each, unless otherwise authorized and approved by the Risk Manager or the City Manager. Contractor will obtain occurrence coverage, excluding Professional Liability, which will be written as claims- made coverage. The insurance will be in force during the life of this Agreement and will not be canceled without thirty (30) days prior written notice to the City by certified mail. City will be named as an additional insured on General Liability which shall provide primary coverage to the City. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. Contractor will furnish certificates of insurance to the Contract Department, with endorsements to City prior to City’s execution of this Agreement. 7. NOTICES The name of the persons who are authorized to give written notice or to receive written notice on behalf of City and on behalf of Contractor under this Agreement. For City For Contractor Name Esequiel Perez Name Mike Mills Title Supervisor Title Project Manager Department Public Works Address 5555 Paseo Del Norte City of Carlsbad Carlsbad, CA 92008 Address 1635 Faraday Ave. Phone No. 760-739-1355 Carlsbad, CA 92008 Email Michael.mills@kengrodyford.com Phone No. 442-339-2192 Each party will notify the other immediately of any changes of address that would require any notice or delivery to be directed to another address. 8. CONFLICT OF INTEREST Contractor shall file a Conflict of Interest Statement with the City Clerk in accordance with the requirements of the City of Carlsbad Conflict of Interest Code. The Contractor shall report investments or interests in all categories. Yes No 9. COMPLIANCE WITH LAWS Contractor will comply with all applicable local, state and federal laws and regulations prohibiting discrimination and harassment and will obtain and maintain a City of Carlsbad Business License for the term of this Agreement. /// DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C □ PSA23-2176FLT City Attorney Approved Version 12/28/2022 3 10. TERMINATION City or Contractor may terminate this Agreement at any time after a discussion, and written notice to the other party. City will pay Contractor's costs for services delivered up to the time of termination, if the services have been delivered in accordance with the Agreement. 11. CLAIMS AND LAWSUITS By signing this Agreement, Contractor agrees it may be subject to civil penalties for the filing of false claims as set forth in the California False Claims Act, Government Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. Contractor further acknowledges that debarment by another jurisdiction is grounds for the City of Carlsbad to terminate this Agreement. 12. JURISDICTIONS AND VENUE Contractor agrees and stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this Agreement is the State Superior Court, San Diego County, California. 13. ASSIGNMENT Contractor may assign neither this Agreement nor any part of it, nor any monies due or to become due under it, without the prior written consent of City. 14. AMENDMENTS This Agreement may be amended by mutual consent of City and Contractor. Any amendment will be in writing, signed by both parties, with a statement of estimated changes in charges or time schedule. /// /// /// /// /// /// /// /// /// /// /// /// /// DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C PSA23-2176FLT City Attorney Approved Version 12/28/2022 4 15.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. CONTRACTOR VINCE DIXON FORD, INC., a California corporation d.b.a. KEN GRODY FORD CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Paz Gomez, Deputy City Manager, Public Works, as authorized by the City Manager Kenneth B. Grody, President (print name/title) By: (sign here) William Raymond, Chief Financial Officer & Secretary (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 B. 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: CINDIE K. McMAHON, City Attorney By: City Attorney DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C PSA23-2176FLT City Attorney Approved Version 12/28/2022 5 EXHIBIT “A” SCOPE OF SERVICES See attached estimate dated April 10, 2023. DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C PSA23-2176FLT Exhibit "A" DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C Ken Grody Fleet Service 5555 Paseo Del Norte Carlsbad, CA 92008 Preliminary Service Estimate Main: 760-739-1355 Fax: 760-594-4251 Web: kengrodyfleetdepartment.com RO# J378761 Date: [04/10/2023 Service Rep: )Mike Mills '------------' Phone:/619-808-8510 Email: jmichael.mills@kengrodyford.com Customer and Vehicle Info: Company: ICity of Carlsbad Work Phone: Customer: !Freddy/ Zek Phone: 1 I Email: i '-------------' '-----------------' ----------------~ Vehicle YMM: !2016 Explorer PD ! Mileage: 1121190 i Plate: 1ID: iA489 ~------ Description of Problem and Recommended Solution: !Replaced output shift solinoid and reinstalled. Retested and transmission started completely failing. Recommend replacing \transmission assembly. Internal failure inside of the transmission. Assembly is on back order with no ETA. Have to remove front 1subframe to gain access to tranmission. Remove transmission, transfer PTU, reinstall and program transmission. Retest \ ' Recommended Parts: 1. /see attached parts list 2. !Labor 3. iPrevious approved repair. 4. 5. 6. 7. 8. 9 .. QTY ! 1 i l 1 i j 1 / ' -·-• ,-i L...__] f7 _,_, i-; i.__J --;-· _:_i UNT PRICE !3,848.80 !2,240.00 ;1,066.00 ;::===========================; 10. LJ j ! L__j 11. 12. 13. 14. Other: iTax !Alignment I l L__j /278.91 i135.00 Parts, Labor Rate & Labor Total: Tax Rate & Tax Total: ]0.00% Grand Total: UNTTOTAL \3,848.80 12,240.00 )1,066.00 !o.oo io.oo [0.00 :o.oo (0.00 10.00 p.oo jo.oo \0.00 10.00 /0.00 I$ 1,154.80 l l i$ o.oo !$ 7,568.71 HRS 1--; i i L___.i I ~ ; ;\ ;--! i ___ , _-1-,, LJ ~ j \ 1 i I ' 1--.i LJ i i ---- ·1 1 l, ; LJ ---- L__j Labor Cost lo lo \o \O io 10 lo Jo !o 'O j 10 i -•1'0 -· --:::=====::::.::: This is a preliminary estimate (process of elimination) to repair your vehicle. Once these components have been replaced/repaired, our technician will perform secondary testing to determine all replaced components are operating as specified by Ford Motor Company and to reassess any other systems that could potentially have been affected by the preliminary repair. Name ________________ _ Signature ____________________ _ PO# _________ _ Date ______ _ PSA23-2176FLT Exhibit "A" (Cont.) DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C Parts Quote 48034 Quote name: 378761.1 Gust ID/ Name: Comment: Part Number DA5Z7000ARM FREIGHT Description AUTOMATIC TR. .. FRGHT FREIGHT Bin 1 spo FRE ... Date: 04/10/23 On On On Bin 2 Hand Hold Order 0 0 0 59 0 0 Page: 1 Printed: 04/10/2023 1 :54 PM Printed By:L.MARTINEZ Qty PC Core List Sell Total 1 F 0.00 3998.67 3598.80 3598.80 1 8 0.00 250.00 250.00 250.00 Sub-Total 3848.80 Tax 278.91 Core Charge 0.00 Estimated Total 4127.71 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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. 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:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD Kevin G. McWilliams KENGR-2 OP ID: 0915 01/18/2023 Kevin G. McWilliams Dealer Protection Group 8659 RESEARCH DRIVE Irvine, CA 92618 Kevin G. McWilliams 949-208-8550 949-208-8560 kmcwilliams@dpg-ins.com Clear Blue Insurance Company Pacific Compensation Insurance Ted Jones Ford, Inc. dba:Ken Grody Ford Vince Dixon Ford, Inc. dba: Ken Grody Ford Carlsbad Ken Grody Redlands, LLC Dba Ken Grody Ford RedlandsGrody Properties, LLC 6211 Beach Blvd Buena Park, CA 90621 1,000,000 X A X 08/01/2022 08/01/2023 3,000,000 X INLCUDED IN GARAGE LIAB. X 10,000,000A BN17-220000270-00 08/01/2022 08/01/2023 XB X 1023868 06/01/2022 06/01/2023 1,000,000 1,000,000 1,000,000 A BN12-220000281-00 08/01/2022 08/01/2023 Limit 3,000,000 Ded.2.5K/5K Certificate holder is included as additional insured with regards to garage liability. City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 947 Murrieta, CA 92564 949-208-8550 28860 11555 BN12-220000281-00Garage Liability Garagekeepers DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C ACORD" I ~ I ~ □ □ ~ ~ Fl □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I I I I □ I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA WC 99 03 16 (Ed 1-14) This endorsement changes the policy to which it is attached and is effective on the policy effective date unless otherwise stated. This endorsement, at 12:01 A.M. standard time, forms a part of01/18/2023effective on 1023868Policy Number Pacific Compensation Insurance Company of the 06/01/2022Policy Effective Date 06/01/2023to 11555NCCI Carrier Code Ted Jones Ford IncInsured Name 26Endorsement No. 518,578 Premium $ Phoenix ,Counter Signed at AZ by Authorized Representative 01/19/2023on 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). You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5.00% of the California workers' compensation premium otherwise due on such remuneration (minimum $100). Schedule Person or Organization Job Description City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 947 Murrieta, CA 92564 Service Work For City Vehicles DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C CopperPoint. Insurance Companies PN 04 99 01 I (Ed. 02-22) 1 of 2PN 04 99 01 I | Doc Type: SFCOR 02-22 POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us - Pacific Compensation Insurance Company (1) General questions regarding your policy should be directed to: Pacific Compensation Insurance Company, 3011 Townsgate, Suite 120 Westlake Village, CA 91361 Telephone: (818) 575-8500 Fax: (818) 575-8576 (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan --1995 (USRP) and the California Workers' Compensation Experience Rating Plan --1995 (ERP). WCIRB contact information is: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerservice@wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1901 Harrison Street, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss-Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: Pacific Compensation Insurance Company, 3011 Townsgate, Suite 120, Westlake Village, CA 91361, Telephone : (818) 575-8500, Fax (818) 575-8576. DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C PN 04 99 01 I (Ed. 02-22) 2 of 2PN 04 99 01 I | Doc Type: SFCOR 02-22 After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice@wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerservice@wcirb.com (email). C. California Department of Insurance - Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4102 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsman@wcirb.com (email). B. California Department of Insurance - Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Copyright, ISO Commercial Risk Services, Inc., 1983 Page 1 of 1  POLICY CHANGES Policy Change Number 8 POLICY NUMBER BN12-220000281-00 POLICY CHANGES EFFECTIVE 1/18/2023 COMPANY Clear Blue Insurance Company NAMED INSURED Ted Jones Ford Inc. dba Ken Grody Ford Buena Park AUTHORIZED REPRESENTATIVE COVERAGE PARTS AFFECTED Commercial Auto CHANGES In consideration of no change in premium, it is hereby agreed that the City of Carlsbad has been added to the Additional Insured – General Liability Coverages – Scheduled Person Or Organization (AU 01 87) form. All other terms and conditions remain unchanged. Total Premium and Fees:$0.00 Authorized Representative Signature DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C RP IL 16 04 08 22 Page 1 of 1 In Witness Whereof: In consideration of your paid premium, Clear Blue Insurance Company is proud to extend to you the coverage offered by this Insurance contract. President, Clear Blue Insurance Company Secretary, Clear Blue Insurance Company DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C } POLICY NUMBER: BN12-220000281-00 COMMERCIAL AUTO AU 01 87 10 21 ADDITIONAL INSURED – GENERAL LIABILITY COVERAGES – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location(s) Of Covered Operations Ken Grody Management Inc 5555 Paseo Del Norte Carlsbad, CA 92008 Ken Grody Management Inc 6211 Beach Blvd Buena Park, CA 90621 Ken Grody Management Inc 4325 Artesia Avenue Fullerton, CA 92833 Ken Grody Management Inc 2198 Palomar Airport Rd Carlsbad, CA 92008 Ken Grody Management Inc 7860 Western Ave Buena Park, CA 90620 Ken Grody Management Inc 5441 Stanton Ave Buena Park, CA 90621 Ken Grody Management Inc 2081 Faraday Ave. Carlsbad, CA 92008 Ken Grody Management Inc 8114 Orangethorpe Ave Buena Park, CA 90621 Ken Grody Management Inc 1121-1141 W Colton Ave Redlands, CA 92374 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C Ken Grody Management Inc 6301-6281 Beach Boulevard Buena Park, CA 90621 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 5555 Paseo Del Norte Carlsbad, CA 92008 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 6211 Beach Blvd Buena Park, CA 90621 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 4325 Artesia Avenue Fullerton, CA 92833 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 2198 Palomar Airport Rd Carlsbad, CA 92008 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 7860 Western Ave Buena Park, CA 90620 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 5441 Stanton Ave Buena Park, CA 90621 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 2081 Faraday Ave. Carlsbad, CA 92008 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 8114 Orangethorpe Ave Buena Park, CA 90621 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 1121-1141 W Colton Ave Redlands, CA 92374 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company 6301-6281 Beach Boulevard Buena Park, CA 90621 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company APN 016-111-23-000 Redlands, CA 92374 Sempra Energy, San Diego Gas & Electric, Southern California Gas Company APN 0169-111-24-0000 Redlands, CA 92374 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C State of California Dept of Transportation 5555 Paseo Del Norte Carlsbad, CA 92008 State of California Dept of Transportation 6211 Beach Blvd Buena Park, CA 90621 State of California Dept of Transportation 4325 Artesia Avenue Fullerton, CA 92833 State of California Dept of Transportation 2198 Palomar Airport Rd Carlsbad, CA 92008 State of California Dept of Transportation 7860 Western Ave Buena Park, CA 90620 State of California Dept of Transportation 5441 Stanton Ave Buena Park, CA 90621 State of California Dept of Transportation 2081 Faraday Ave. Carlsbad, CA 92008 State of California Dept of Transportation 8114 Orangethorpe Ave Buena Park, CA 90621 State of California Dept of Transportation 1121-1141 W Colton Ave Redlands, CA 92374 State of California Dept of Transportation 6301-6281 Beach Boulevard Buena Park, CA 90621 State of California Dept of Transportation APN 016-111-23-000 Redlands, CA 92374 State of California Dept of Transportation APN 0169-111-24-0000 Redlands, CA 92374 State of California Department of General Services, Office of Fleet & Asset Management 5555 Paseo Del Norte Carlsbad, CA 92008 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C State of California Department of General Services, Office of Fleet & Asset Management 6211 Beach Blvd Buena Park, CA 90621 State of California Department of General Services, Office of Fleet & Asset Management 4325 Artesia Avenue Fullerton, CA 92833 State of California Department of General Services, Office of Fleet & Asset Management 2198 Palomar Airport Rd Carlsbad, CA 92008 State of California Department of General Services, Office of Fleet & Asset Management 7860 Western Ave Buena Park, CA 90620 State of California Department of General Services, Office of Fleet & Asset Management 5441 Stanton Ave Buena Park, CA 90621 State of California Department of General Services, Office of Fleet & Asset Management 2081 Faraday Ave. Carlsbad, CA 92008 State of California Department of General Services, Office of Fleet & Asset Management 8114 Orangethorpe Ave Buena Park, CA 90621 State of California Department of General Services, Office of Fleet & Asset Management 1121-1141 W Colton Ave Redlands, CA 92374 State of California Department of General Services, Office of Fleet & Asset Management 6301-6281 Beach Boulevard Buena Park, CA 90621 State of California Department of General Services, Office of Fleet & Asset Management APN 016-111-23-000 Redlands, CA 92374 State of California Department of General Services, Office of Fleet & Asset Management APN 0169-111-24-0000 Redlands, CA 92374 City of San Marcos 5555 Paseo Del Norte Carlsbad, CA 92008 City of San Marcos 6211 Beach Blvd Buena Park, CA 90621 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C City of San Marcos 4325 Artesia Avenue Fullerton, CA 92833 City of San Marcos 2198 Palomar Airport Rd Carlsbad, CA 92008 City of San Marcos 7860 Western Ave Buena Park, CA 90620 City of San Marcos 5441 Stanton Ave Buena Park, CA 90621 City of San Marcos 2081 Faraday Ave. Carlsbad, CA 92008 City of San Marcos 8114 Orangethorpe Ave Buena Park, CA 90621 City of San Marcos 1121-1141 W Colton Ave Redlands, CA 92374 City of San Marcos 6301-6281 Beach Boulevard Buena Park, CA 90621 City of San Marcos APN 016-111-23-000 Redlands, CA 92374 City of San Marcos APN 0169-111-24-0000 Redlands, CA 92374 City of Santa Ana 5555 Paseo Del Norte Carlsbad, CA 92008 City of Santa Ana 6211 Beach Blvd Buena Park, CA 90621 City of Santa Ana 4325 Artesia Avenue Fullerton, CA 92833 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C City of Santa Ana 2198 Palomar Airport Rd Carlsbad, CA 92008 City of Santa Ana 7860 Western Ave Buena Park, CA 90620 City of Santa Ana 5441 Stanton Ave Buena Park, CA 90621 City of Santa Ana 2081 Faraday Ave. Carlsbad, CA 92008 City of Santa Ana 8114 Orangethorpe Ave Buena Park, CA 90621 City of Santa Ana 1121-1141 W Colton Ave Redlands, CA 92374 City of Santa Ana 6301-6281 Beach Boulevard Buena Park, CA 90621 City of Santa Ana APN 016-111-23-000 Redlands, CA 92374 City of Santa Ana APN 0169-111-24-0000 Redlands, CA 92374 City of Buena Park 5555 Paseo Del Norte Carlsbad, CA 92008 City of Buena Park 6211 Beach Blvd Buena Park, CA 90621 City of Buena Park 4325 Artesia Avenue Fullerton, CA 92833 City of Buena Park 2198 Palomar Airport Rd Carlsbad, CA 92008 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C City of Buena Park 7860 Western Ave Buena Park, CA 90620 City of Buena Park 5441 Stanton Ave Buena Park, CA 90621 City of Buena Park 2081 Faraday Ave. Carlsbad, CA 92008 City of Buena Park 8114 Orangethorpe Ave Buena Park, CA 90621 City of Buena Park 1121-1141 W Colton Ave Redlands, CA 92374 City of Buena Park 6301-6281 Beach Boulevard Buena Park, CA 90621 City of Buena Park APN 016-111-23-000 Redlands, CA 92374 City of Buena Park APN 0169-111-24-0000 Redlands, CA 92374 Super Center Concepts Inc DBA Superior Grocers 5555 Paseo Del Norte Carlsbad, CA 92008 Super Center Concepts Inc DBA Superior Grocers 6211 Beach Blvd Buena Park, CA 90621 Super Center Concepts Inc DBA Superior Grocers 4325 Artesia Avenue Fullerton, CA 92833 Super Center Concepts Inc DBA Superior Grocers 2198 Palomar Airport Rd Carlsbad, CA 92008 Super Center Concepts Inc DBA Superior Grocers 7860 Western Ave Buena Park, CA 90620 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C Super Center Concepts Inc DBA Superior Grocers 5441 Stanton Ave Buena Park, CA 90621 Super Center Concepts Inc DBA Superior Grocers 2081 Faraday Ave. Carlsbad, CA 92008 Super Center Concepts Inc DBA Superior Grocers 8114 Orangethorpe Ave Buena Park, CA 90621 Super Center Concepts Inc DBA Superior Grocers 1121-1141 W Colton Ave Redlands, CA 92374 Super Center Concepts Inc DBA Superior Grocers 6301-6281 Beach Boulevard Buena Park, CA 90621 Super Center Concepts Inc DBA Superior Grocers APN 016-111-23-000 Redlands, CA 92374 Super Center Concepts Inc DBA Superior Grocers APN 0169-111-24-0000 Redlands, CA 92374 City of Oceanside 5555 Paseo Del Norte Carlsbad, CA 92008 City of Oceanside 6211 Beach Blvd Buena Park, CA 90621 City of Oceanside 4325 Artesia Avenue Fullerton, CA 92833 City of Oceanside 2198 Palomar Airport Rd Carlsbad, CA 92008 City of Oceanside 7860 Western Ave Buena Park, CA 90620 City of Oceanside 5441 Stanton Ave Buena Park, CA 90621 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C City of Oceanside 2081 Faraday Ave. Carlsbad, CA 92008 City of Oceanside 8114 Orangethorpe Ave Buena Park, CA 90621 City of Oceanside 1121-1141 W Colton Ave Redlands, CA 92374 City of Oceanside 6301-6281 Beach Boulevard Buena Park, CA 90621 City of Oceanside APN 016-111-23-000 Redlands, CA 92374 City of Oceanside APN 0169-111-24-0000 Redlands, CA 92374 City of Banning 1121-1141 W Colton Ave Redlands, CA 92374 City of Redlands 1121-1141 W Colton Ave Redlands, CA 92374 Enterprise Rent-A-Car Company of Los Angeles, LLC 1121-1141 W Colton Ave Redlands, CA 92374 Centra ISAOA 1121-1141 W Colton Ave Redlands, CA 92374 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 5555 Paseo Del Norte Carlsbad, CA 92008 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 6211 Beach Blvd Buena Park, CA 90621 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 4325 Artesia Avenue Fullerton, CA 92833 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 2198 Palomar Airport Rd Carlsbad, CA 92008 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 7860 Western Ave Buena Park, CA 90620 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 5441 Stanton Ave Buena Park, CA 90621 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 2081 Faraday Ave. Carlsbad, CA 92008 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 8114 Orangethorpe Ave Buena Park, CA 90621 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 1121-1141 W Colton Ave Redlands, CA 92374 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services 6301-6281 Beach Boulevard Buena Park, CA 90621 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services APN 016-111-23-000 Redlands, CA 92374 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services APN 0169-111-24-0000 Redlands, CA 92374 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Under Section II – General Liability Coverages: A.Paragraph D. Who Is An Insured is amended to include as an “insured” the person(s) or organization(s) shown in the Schedule, but 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(s)” at the location(s) designated above. 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”. B.With respect to the insurance afforded to these additional “insureds”, the following is added to Paragraph F. Limits Of Insurance – General Liability Coverages: 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: DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C 1.Required by the contract or agreement; or 2.Available under the applicable General Liability Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. AU 01 87 10 21 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 DocuSign Envelope ID: AA786F59-C4D3-4952-A3B4-10F38902159C