HomeMy WebLinkAboutCC Resolution 11822 (Performance Building System)RESOLUTION NO. 11822
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN RAFAEL
AUTHORIZING THE CITY MANAGER TO SIGN A PROFESSIONAL
SERVICES AGREEMENT WITH DAN BAY FOR A PERFORMANCE
BUILDING SYSTEM MANAGEMENT PLAN FOR THE FIRE
DEPARTMENT IN AN AMOUNT NOT TO EXCEED $29,250.00
(ONE -YEAR TERM FROM 8/1/05 AND ENDING ON 7/31/06)
BE IT RESOLVED by the Council of the City of San Rafael as follows:
WHEREAS, The Fire Department functions with four divisions, three 24-hour shifts,
resulting in 18 work groups, as well as Administrative, Training, and Fire Prevention divisions;
and
WHEREAS, the decentralized design leaves room for communication and issue
solving voids with negative outcomes such as: poor competence, low productivity, low moral,
and poor labor relations; and
WHEREAS, there is a substantial need to improve the quality of communications
between the personnel within and between the groups, supervisors, managers, and between
divisions with positive outcome, more accountability for compliance, team functionality, conflict
resolution; and
WHEREAS, Dan Bay has submitted a proposal for the Performance Building System
management plan in an amount not to exceed $29,250.00.
NOW, THEREFORE, BE IT RESOLVED by the Council of the City of San
Rafael that the City Manager is hereby authorized to sign a professional services agreement with
Dan Bay for the Performance Building System in an amount not to exceed $29,250.00.
1)
I, JEANNE M. LEONCINI, Clerk of the City of San Rafael, hereby certify that the
foregoing Resolution was duly and regularly introduced and adopted at a reg lar meeting of the
City Council of said City held on Monday, the 15th day of August, 2005,
by the following vote, to wit:
AYES: COUNCILMEMBERS: Cohen, Heller, Miller, Phillips and Mayor Boro
NOES: COUNCILMEMBERS: None
ABSENT: COUNCILMEMBERS: None
JEAANE M. LEONCIlVI, City Clerk
AGREEMENT
This Agreement is made and entered into as of thel 5thday of AUGUST , 2005, by
and between the CITY OF SAN RAFAEL (hereinafter "CITY"), and Dan Bay, an individual
(hereinafter "CONTRACTOR").
I 014"A y
WHEREAS, City requires the professional services of a contractor that is experienced in
organizational development and performance management.
WHEREAS, CONTRACTOR has the necessary experience in providing professional
services and advice related to fire service organizations and municipal governments.
WHEREAS, CONTRACTOR has submitted a proposal to City and has affirmed its
willingness and ability to perform such work.
AGREEMENT
NOW, THEREFORE, the parties hereby agree as follows:
1. PROJECT COORDINATION.
A. CITY. The City Manager shall be the representative of the CITY for all purposes
under this Agreement. The Fire Chief, is hereby designated the PROJECT MANAGER for the
CITY, and said PROJECT MANAGER shall supervise all aspects of the progress and execution of
this Agreement.
B. CONTRACTOR. CONTRACTOR shall assign a single PROJECT DIRECTOR
to have overall responsibility for the progress and execution of this Agreement for
CONTRACTOR. Dan Bay is hereby designated as the PROJECT DIRECTOR for
CONTRACTOR. Should circumstances or conditions subsequent to the execution of this
Agreement require a substitute PROJECT DIRECTOR for any reason, the CONTRACTOR shall
notify the CITY within ten (10) business days of the substitution
2. DUTIES OF CONTRACTOR.
CONTRACTOR shall perform the duties and/or provide services as set forth in Exhibit
"A", Scope of Services.
3. DUTIES OF CITY.
CITY shall pay the compensation as provided in Paragraph 4, and provide logistical
assistance to CONTRACTOR in order to accomplish project goals and activities.
4. COMPENSATION.
For the full performance of the services described herein by CONTRACTOR, CITY shall
pay CONTRACTOR $29,250 based on the completion of tasks as set forth in Exhibit "A".
Payments will be made according to the schedule described in Exhibit "A", upon receipt by the
PROJECT MANAGER of itemized invoices submitted by CONTRACTOR.
5. TERM OF AGREEMENT.
The term of this Agreement shall be for one year commencing on August 1, 2005 and
ending on July 31, 2006. Upon mutual agreement of the parties, and subject to the approval of the
City Manager, the term of this Agreement may be extended for an additional period of up to one
year.
6. TERMINATION.
A. Discretionary. Either party may terminate this Agreement without cause upon
thirty (30) days written notice mailed or personally delivered to the other party.
B. Cause. Either party may terminate this Agreement for cause upon fifteen (15) days
written notice mailed or personally delivered to the other party, and the notified party's failure to
cure or correct the cause of the termination, to the reasonable satisfaction of the party giving such
notice, within such fifteen (15) day time period.
C. Effect of Termination. Upon receipt of notice of termination, neither party shall
incur additional obligations under any provision of this Agreement without the prior written consent
of the other.
D. Return of Documents. Upon termination, any and all CITY documents or
materials provided to CONTRACTOR and any and all of CONTRACTOR's documents and
materials prepared for or relating to the performance of its duties under this Agreement, shall be
delivered to CITY as soon as possible, but not later than thirty (30) days after termination.
7. OWNERSHIP OF DOCUMENTS.
The written documents and materials prepared by the CONTRACTOR in connection with
the performance of its duties under this Agreement, shall be the sole property of CITY, except
those already owned by CONTRACTOR and used in the delivery of services. CITY may use said
property for any purpose, including projects not contemplated by this Agreement.
2
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Upon reasonable notice, CONTRACTOR shall make available to CITY, or its agent, for
inspection and audit, all documents and materials maintained by CONTRACTOR in connection
with its performance of its duties under this Agreement. CONTRACTOR shall fully cooperate
with CITY or its agent in any such audit or inspection.
9. ASSIGNABILITY.
The parties agree that they shall not assign or transfer any interest in this Agreement nor the
performance of any of their respective obligations hereunder, without the prior written consent of
the other party, and any attempt to so assign this Agreement or any rights, duties or obligations
arising hereunder shall be void and of no effect.
A. During the term of this Agreement, CONTRACTOR shall maintain, at no expense
to CITY, the following insurance policies:
1. A comprehensive general liability insurance policy in the minimum amount
of one million ($1,000,000) dollars per occurrence for death, bodily injury, personal injury, or
property damage;
2. An automobile liability (owned, non -owned, and hired vehicles) insurance
policy in the minimum amount of one million ($1,000,000) dollars per occurrence;
3. If any licensed professional performs any of the services required to be
performed under this Agreement, a professional liability insurance policy in the minimum amount
of one million $1,000,000) dollars to cover any claims arising out of the CONTRACTOWs
performance of services under this Agreement.
B. The insurance coverage required of the CONTRACTOR by section 10. A. shall
also meet the following requirements:
1. The insurance shall be primary with respect to any insurance or coverage
maintained by CITY and shall not call upon CITY's insurance or coverage for any contribution;
2. Except for professional liability insurance, the insurance policies shall be
endorsed for contractual liability and personal injury;
3. Except for professional liability insurance, the insurance policies shall be
specifically endorsed to include the CITY, its officers, agents, employees, and volunteers, as
additionally named insureds under the policies.
N
4. CONTRACTOR shall provide to City's Risk Manager, (a) Certificates of
Insurance evidencing the insurance coverage required herein, and (b) specific endorsements naming
CITY, its officers, agents, employees, and volunteers, as additional named insureds under the
policies.
5. The insurance policies shall provide that the insurance carrier shall not
cancel, terminate or otherwise modify the terms and conditions of said insurance policies except
upon thirty (30) days written notice to City's Risk Manager.
6. If the insurance is written on a Claims Made Form, then, following
termination of this Agreement, said insurance coverage shall survive for a period of not less than
five years;
7. The insurance policies shall provide for a retroactive date of placement
coinciding with the effective date of this Agreement;
8. The insurance shall be approved as to form and sufficiency by PROJECT
MANAGER and the City Attorney.
C. If it employs any person, CONTRACTOR shall maintain worker's compensation
and employer's liability insurance, as required by the State Labor Code and other applicable laws
and regulations, and as necessary to protect both CONTRACTOR and CITY against all liability
for injuries to CONTRACTOR's officers and employees.
D. Any deductibles or self-insured retentions in CONTRACTOR's insurance policies
must be declared to and approved by the City's Risk Manager and the City Attorney. At CITY's
option, the deductibles or self-insured retentions with respect to CITY shall be reduced or
eliminated to CITY's satisfaction, or CONTRACTOR shall procure a bond guaranteeing payment
of losses and related investigations, claims administration, attorney's fees and defense expenses.
11. INDEMNIFICATION.
CONTRACTOR shall indemnify, release, defend and hold harmless CITY, its officers,
agents, employees, and volunteers, against any claim, demand, suit, judgment, loss, liability or
expense of any kind, including attorney's fees and administrative costs, arising out of or resulting in
any way, in whole or in part, from any acts or omissions, intentional or negligent, of
CONTRACTOR or CONTRACTOR'S officers, agents and employees in the performance of
their duties and obligations under this Agreement."
12. NONDISCRIMINATION.
CONTRACTOR shall not discriminate, in any way, against any person on the basis of age,
sex, race, color, religion, ancestry, national origin or disability in connection with or related to the
performance of its duties and obligations under this Agreement.
13. COMPLIANCE WITH ALL LAWS.
CONTRACTOR shall observe and comply with all applicable federal, state and local laws,
ordinances, codes and regulations, in the performance of its duties and obligations under this
Agreement. CONTRACTOR shall perform all services under this Agreement in accordance with
these laws, ordinances, codes and regulations. CONTRACTOR shall release, defend, indemnify
and hold harmless CITY, its officers, agents and employees from any and all damages, liabilities,
penalties, fines and all other consequences from any noncompliance or violation of any laws,
ordinances, codes or regulations.
14. NO THIRD PARTY BENEFICIARIES.
CITY and CONTRACTOR do not intend, by any provision of this Agreement, to create in
any third party, any benefit or right owed by one party, under the terms and conditions of this
Agreement, to the other party.
15. NOTICES.
All notices and other communications required or permitted to be given under this
Agreement, including any notice of change of address, shall be in writing and given by personal
delivery, or deposited with the United States Postal Service, postage prepaid, addressed to the
parties intended to be notified. Notice shall be deemed given as of the date of personal delivery, or
if mailed, upon the date of deposit with the United States Postal Service. Notice shall be given as
follows:
TO CITY: John Montenero, Fire Chief
Project Manager
City of San Rafael
1400 Fifth Ave. (P.O. Box 151560)
San Rafael, CA 944915-1560
TO CONTRACTOR: Dan Bay, Project Director
65 Vallejo Way
San Rafael, CA 94903
16. INDEPENDENT CONTRACTOR.
For the purposes, and for the duration, of this Agreement, CONTRACTOR, its officers,
agents and employees shall act in the capacity of an Independent Contractor, and not as employees
of the CITY. CONTRACTOR and CITY expressly intend and agree that the status of
CONTRACTOR, its officers, agents and employees be that of an Independent Contractor and not
that of an employee of CITY.
5
17. ENTIRE AGREEMENT -- AMENDMENTS.
A. The terms and conditions of this Agreement, all exhibits attached, and all
documents expressly incorporated by reference, represent the entire Agreement of the parties with
respect to the subject matter of this Agreement.
B. This written Agreement shall supersede any and all prior agreements, oral or
written, regarding the subject matter between the CONTRACTOR and the CITY.
C. No other agreement, promise or statement, written or oral, relating to the subject
matter of this Agreement, shall be valid or binding, except by way of a written amendment to this
Agreement.
D. The terms and conditions of this Agreement shall not be altered or modified except
by a written amendment to this Agreement signed by the CONTRACTOR and the CITY.
E. If any conflicts arise between the terms and conditions of this Agreement, and the
terms and conditions of the attached exhibits or the documents expressly incorporated by reference,
the terms and conditions of this Agreement shall control.
18. SET-OFF AGAINST DEBTS.
CONTRACTOR agrees that CITY may deduct from any payment due to
CONTRACTOR under this Agreement, any monies which CONTRACTOR owes CITY under
any ordinance, agreement, contract or resolution for any unpaid taxes, fees, licenses, assessments,
unpaid checks or other amounts.
19. WAIVERS.
The waiver by either party of any breach or violation of any term, covenant or condition of
this Agreement, or of any ordinance, law or regulation, shall not be deemed to be a waiver of any
other term, covenant, condition, ordinance, law or regulation, or of any subsequent breach or
violation of the same or other term, covenant, condition, ordinance, law or regulation. The
subsequent acceptance by either party of any fee, performance, or other consideration which may
become due or owing under this Agreement, shall not be deemed to be a waiver of any preceding
breach or violation by the other party of any term, condition, covenant of this Agreement or any
applicable law, ordinance or regulation.
20. COSTS AND ATTORNEY'S FEES.
The prevailing party in any action brought to enforce the terms and conditions of this
Agreement, or arising out of the performance of this Agreement, may recover its reasonable costs
(including claims administration) and attorney's fees expended in connection with such action.
21. CITY BUSINESS LICENSE / OTHER TAXES,.
CONTRACTOR shall obtain and maintain during the duration of this Agreement, a CITY
business license as required by the San Rafael Municipal Code. CONTRACTOR shall pay any
and all state and federal taxes and any other applicable taxes. CITY shall not be required to pay
for any work performed under this Agreement, until CONTRACTOR has provided CITY with
a completed Internal Revenue Service Form W-9 (Request for Taxpayer Number and
Certification).
22. APPLICABLE LAW.
The laws of the State of California shall govern this Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the day, month
and year first above written.
CITY OF SAN RAFAEL
ROD GOULD, City Manager
ATTEST:
ANNE M. LEONCW, City Clerk
Y T. RADGHIANTI, gi!Y Attorney
7
CONTRACTOR
By:
Name: DAN BAY
1>
EXHIBIT "A"
SCOPE OF SERVICES
The following is a general list of what CONTRACTOR will do for City, including price, and
schedule. The implementation tasks may be modified as the project progresses based on
Department and City needs.
Overview
Enhance individual, team, operational, and interpersonal functions through implementation of a
performance building system. In particular, install a team -based self-assessment approach that
emphasizes continuous quality improvement.
Design Objectives
(1) Improve the ability of managers and supervisors to direct and monitor individual and
team practices, critically analyze performance, and build and maintain a positive culture.
(2) Strengthen the competency and confidence of managers and supervisors to recognize and
take prompt, preventive action to address performance problem behaviors and to
understand their impact on the individual, team, and organization.
(3) Improve the approachability of managers and supervisors and strengthen their
relationship with subordinate staff.
(4) Reinforce positive, department -wide team -based performance behaviors.
(5) Promote employee buy -in and encourage a supportive attitude within the Department's
culture for effective performance systems, self -initiative, and related personal behaviors
based on a set of best practices.
(6) Enhance the leadership path for all personnel in operational and interpersonal areas, in
particular supervisors.
(7) Strengthen communication throughout all levels of the department, in particular between
supervisors and subordinate personnel to foster more openness about issues that inhibit
individual and team performance.
(8) Modify departmental systems and practices to improve accountability, organizational
discipline, and support desired performance behaviors.
(9) Strengthen professional development initiatives by providing self -study exercises to line
supervisors and personnel.
(10) Communicate key messages and information to all employees to build understanding and
support for the new system.
The following defines the principal tasks to install the program in the department. Tasks are
categorized under preparation, implementation, and follow-up/maintenance. They are not listed
in order of importance or chronology.
T
Preparation
Preparation is key to building a viable system. In particular, a broad range of employee input
must be tapped to customize the model to reflect the individual, supervisory, and team best
practices that will be a foundation for the new system.
Principal Tasks:
• Assess operational and interpersonal functions; define issues. Conduct limited interviews
with leadership team, union representatives, and key employees.
• Review relevant Department documents, e.g., strategic, operational, and training plans,
personnel appraisal, and code of conduct.
• Commence oral and written communications, e.g., memorandums, newsletters.
• Designate Department personnel who will work with the project consultant to be developed
as internal subject experts, and who may assume oversight responsibility for the
administrative and technical maintenance of the program. Note: ideal qualities — strong
subject interest, ability to lead, persistent, and persuasive.
• Provide an orientation for key personnel, union leaders, and employee groups.
• Prepare leadership team for implementation enabling members to rapidly incorporate
elements of the WPB tools and processes into their personal styles and practices. Requires
completion of initial orientation and feedback module outlined in implementation section,
plus a second course and/or one-to-one tutoring on command level processes and tools, e.g.,
application of performance planner, triage, and risk analysis.
• Review and customize assessment instrument and initial guidelines, define organizational
process, and determine reporting requirements.
• Explore the potential for integrating and/or linking the performance model with other
organizational systems, e.g., appraisal, promotional, professional/of cer development,
academy, and other training initiatives.
• Finalize implementation strategy, plan, and training materials.
Summary of Key Outcomes
• Conduct limited assessment of operational and interpersonal functions; define issues
• Draft and publish a series of communications
• Provide an orientation for leadership team, key personnel and union leaders
• Prepare leadership team for implementation
• Explore the potential for integrating and/or linking the performance model with other
organizational systems
• Customize performance system tools and guidelines and finalize implementation plan
(T-
Implementation
T
Implementation
Implementation activities involve two major activities: conducting feedback sessions for all
employees and facilitation training and a walk through of the AIM exercise for supervisors and
line personnel. The purpose of the feedback sessions is to provide an opportunity for input and
validation of the proposed system, as well as identifying obstacles and solutions to current
challenges.
Principal Tasks:
Conduct orientation and feedback sessions for all Department personnel to include the
following...
— present the purpose and rationale for the system
— provide participants an understanding of how the system and related tools were
developed (engage in five exercises)
— collect input on ways to improve the process
— present the tools and collect input on validity and use
— have participants complete a case study simulating a workplace problem for the
purpose of testing their application of the system; administer a survey to measure
the perceived usefulness of the process; consultant will also be available for
follow-up
• Conduct select training, e.g., one-to-one coaching, at executive and command levels to
support implementation and ongoing monitoring of the new system.
• Design self -training exercise to be delivered in conjunction with the initial performance
assessment.
• Provide facilitation training, a final review of guidelines and related processes, and simulated
assessment for all personnel prior to official launch.
• Draft and distribute Guidelines for review by employees; finalize Guidelines.
Summary of Key Outcomes
• Conduct orientation and feedback sessions for all personnel
• Provide select training, e.g., one-to-one coaching, at executive and command levels
• Design self -training exercises
• Provide facilitation training and conduct simulated assessment
• Employees review draft Guidelines; finalize for implementation
3
Maintenance
Maintenance activities are designed to provide continuity and technical support for the
Department staff during the first and second years.
Principal Tasks:
• Assist Department personnel in monitoring initial implementation results, and provide post -
implementation debriefs with managers and/or supervisors through the first and second years
of operating the system.
• Design additional self -training exercises to be delivered in conjunction with subsequent
assessments through first year.
• Determine additional support requirements.
• Revise Guidelines as needed.
Summary of Key Outcomes
• Support Department personnel, in particular the leadership team, during initial implementation and
ongoing application and management of the new system through first and second years
• Design additional self -training exercises
• Revise guidelines as needed
Included documents, tools and processes
• Guidelines
• Assessment Instrument
• Facilitation Guide
• Performance Planners B
Individual/Team (AIM Exercise)
• Performance Planner B Battalion
• Risk Analysis
• Pre and Post Assessment Protocols
• Intervention Protocol
• Chief Officer's Implementation Guide
• Sample Application Scenarios
• Frequently Asked Questions
• Self -study training Exercises
Timetable
It is anticipated that the three phases will span a period of ten to eleven months of FY 05-06. It
is estimated that the preparation phase will be completed within 30 to 60 days from the start date.
Similarly, it is anticipated that the implementation phase will be completed within the next 60 to
90 days, depending on the Department's training calendar. The maintenance phase will then
commence, including two assessment exercises over the next 6 to 7 months. The following table
illustrates the timetable for each phase.
T
Estimated Timetable
Phase
Period
Preparation
I 30 — 60 days
Implementation
60 — 90 days
Maintenance
6 — 7 months
The following chart illustrates an approximate timeline for each phase during FY 05-06 based on
an August/September start date.
Phase Aug Sept Oct Nov Dec Jan Feb Mar Apr May June
Prep
Imp
Main I I I I I
Cost
Contract cost for the FY 04-05 period is $29,250. The following table illustrates the cost for
each phase. Billing for services will occur following completion of major tasks at the mid -point
and end of each phase. Total billings will not exceed $29,250.
FY 04-05 Cost
Phase
Cost
Preparation I
$8,200
Implementation
12,800
Maintenance
8,250
Total
$29,250
5
P, y!Number DECLARATIONS PAGE AMENDED JUL 1 2005
9/ )Y-8259-1 STATE FARM GENERAL INSURANCE COMPANY
6400 STATE FARM DR, ROHNERT PARK CA 94926-0001
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
02-2089-F150 T
BUSINESS POLICY - SPECIAL FORM 3
Named Insured and Mailing Address
BAY, DANIEL
65 VALLEJO WAY
SAN RAFAEL CA 94903-2337
Cov A - Inflation Coverage Index: N/A
Cov B - Consumer Price Index: 189.7
AUTOMATIC RENEWAL - If the POLICY PERIOD is shov.n as 12 MONTHS, this policy will be renewed automatically
subject to the premiums, rules and forms in effect for each succeeding policy period If his policy is terminated, we will
give you and the Mortgagee/Lienholder written notice in compliance wl h the policy provisions or as required by law.
Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the
Effective Date: OCT 19 2004 premises location.
Expiration Date: OCT 19 2005
Named Insured: Individual
Location of Covered Premises:
65 VALLEJO WAY
SAN RAFAEL CA 94903-2337
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products -Completed Operations
(PCO) Aggregate
General Aggregate (Other
Than PCO)
Forms, Options, and Endorsements
Special Form 3
Amendatory Endorsement
Tree Debris Removal
Policy Endorsement
Policy Endorsement -Business
Glass Deductible - Section I
Advertising Injury Excl
Limits of Insurance
Excluded
$ 5,500
$ Actual Loss
Your policy is amended JUL 1 2005
ADDL INSURED NAME & ADDRESS ADDED
Occupancy: Uttice
Deductibles - Section I
1,000,000 zz :oi o and t
5, 000 $ 1,000 Basic
Excluded
$ 2,000,000
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
policy.
Endorsement Premium None
FP -6143
FE -6205
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FE -6451
Renewal Year
FE -6506.2
Years in Business
FE -6464
Claim Record
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our policy consists of this page, any endorsements (415) 283-3240
nd the policy form. PLEASE KEEP THESE TOGETHER.
Agent
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Policy Number
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BUSINESS POLICY - SPECIAL FORM 3
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Amendatory Collapse
Terrorism Insurance Cov Notice
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IMPORTANT NOTICE:
CONTINUED FROM FRONT SIDE
FE -6313.1
FE -6312
FE -6346
FE -6510
FE -6551
FE -6999
FE -6320
California law requires us to provide you with information for filing complaints with the State Insurance
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Complaints should be filed only after you and State Farm or your agent or other company representative
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Or call toll free: 1 -500 -927 -HELP
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(o1f2176c) (o1f2175a)
SM Policy No. 97-QY-8259-1 FE -6320
(7/66)
ADDITIONAL INSURED ENDORSEMENT =_•
DESIGNATED PREMISES ONLY
IN3Yl�NC�
m
Policy NO.: 97-QY-8259-1
Named Insured: BAY, DANIEL
Name of Additional Insured: THE CITY OF SAN RAFAEL
ITS OFFICERS & EMPLOYEES
Address of Additional Insured: PO BOX 15156
SAN RAFAEL CA 94915
Interest of Additional Insured: CONTRACT FOR SERVICES
Location of Premises: LOCATION PER CONTRACT
The word "insured", wherever used in this policy, also includes the designated person or organization named above
as Additional Insured under the provisions of the policy Sections shown below as applicable by an "X" to the extent
indicated.
❑ SECTION I. This applies only to COVERAGE A - BUILDINGS.
❑ SECTION I. This applies only to COVERAGE B - BUSINESS PERSONAL PROPERTY.
Description of Property:
❑X SECTION If. This applies only to COVERAGE L - BUSINESS LIABILITY and COVERAGE M -
MEDICAL PAYMENTS and then only with respect to the ownership, maintenance or use of
the premises designated above and operations necessary or incidental thereto. These
SECTION II coverages do not apply to:
1. structural alterations or new construction performed by or on behalf of the designated person or
organization;
2. personal injury caused by the designated person or organization;
3. liability the designated person or organization assumed under a contract; or
4. products -completed operations hazard arising out of goods or inventory which are not sold or
distributed by you or arising out of the manufacturing or packaging of such goods or inventory.
All other provisions of the policy apply.
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(7/66) Printed in U.S.A.
�- State Farm General Insurance Co, y
Mr 6400 State Faim Drive
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THE CITY OF SAN RAFAEL
ITS OFFICERS & EMPLOYEES
PO BOX 15156
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Insured: BAY, DANIEL
Location: 65 VALLEJO WAY
SAN RAFAEL CA
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POLICY NUMBL , 97-OY-8259-1
Business- Office Policy
OCT 19 2005 to OCT 19 2006
DATE DUE PLEASE PAY THIS AMOUNT
j PAID BY SPECIFIED PARTY
Coverages and Limits
Section I
A Buildings Excluded
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C Loss of Income Actual Loss
Deductibles - Section I
Basic 1,000
Other deductibles may
apply - refer to policy
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M Medical Payments 5 00
Gen Aggregate (Other than PCO) 2,000,000
Products -Completed Operations 2,000,000
(PCO Aggregate)
FE -6205
Annual Premium $241.00
FE -6451
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Total Amount $250.00
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FE -6510
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FE -6999
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FE -5383
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See reverse side for important information.
Please keep this part for your record.
NOTE: DO NOT PAY. THE PREMIUM IS
BEING PAID BY THE SPECIFIED PARTY.
CONTINUED FROM FRONT
NOTICE TO POLICYHOLDER:
For a comprehensive description of coverages and forms, please refer to your policy.
Policy changes requested before the "Date Prepared", which appear on this notice, are effective on the Renewal Date of this
policy unless otherwise indicated by a separate endorsement, binder, or amended declarations. Any coverage forms attached
to this notice are also effective on the Renewal Date of this policy.
Policy changes requested after the "Date Prepared" will be sent to you as an amended declarations or as an endorsement to
your policy. Billing for any additional premium for such changes will be mailed at a later date.
If, during the past year, you've acquired any valuable property items, made any improvements to insured property, or have any
questions about your insurance coverage, contact your State Farm agent.
Please keep this with your policy.
(oi f008g0 Rev. 10-2003
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State Farm General Insurance Cc ,y
6400 State Farm Drive
Rohnert Park, CA 94926-0001
T-02- 2089-F150 FU 3
THE CITY OF SAN RAFAEL
ITS OFFICERS & EMPLOYEES
PO BOX 15156
SAN RAFAEL CA 94915
Forms, Options, and Endorsements
Inc Cost and Demolition Cov
Policy Endorsement -Business
Ag6nif JERRY VERDI CPCU
Telepwna (415) 283-3240
FE -6587
FE -6610
IF YOU HAVE MOVED, PLEASE CONTACT YOUR AGENT,
RENEWAL Cr'"TIFICATE SCHEDULE PAGE
POLICY NUMBL. 97-QY-8259-1
Business- Office Policy
OCT 19 2005 to OCT 19 2006
DATE DUE PLEASE PAY THIS AMOUNT
CONTINUED
T -2089-F150 F
17 3365 6684
Please keep this part for your record.
Prepared AUG 10 2005