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HomeMy WebLinkAboutA6666 - SHELTER FROM THE STORM SUBRECIPIENT AGREEMENT THIS AGREEMENT(herein "Agreement"), is made and entered into this-L day of 4 a r 2015, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Shelter From The Storm. Inc. ,(herein"Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R.Section 570 et seq.("Regulations");and WHEREAS,the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act;and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW,THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specked in such application. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specked in Section 2.2, within ten (10)days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive or due to receiver $20,000.00 or more from the City during the 2015—2016 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve(12)months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to ORIGINAL BID AND/OR AGREEMENT City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 315�of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed SEVEN THOUSAND AND FIVE HUNDRED DOLLARS 7 500.OD)(the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City monthly statements on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Angelina Coe, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the chief administrative officer of City. 3.3 Prohibition Against Subcontractina or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred,voluntarily or by operation of law, without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations -2- promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the dose of the program. 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable: (a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; (c) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086,and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); 0) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c)and 570.503(b)(8); (1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; (m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; -3 - (n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); (o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate to the acceptance and use of federal funds under the federally- assisted program; (p) Title VI of the Civil Rights Act of 1964(P.L. 88-352)and implementing regulations issued at 24 CFR Part 1; (q) Title VIII of the Civil Rights Act of 1968(P.L. 90-284)as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 at seg.); (s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and (t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: (i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or (ii) Not used in accordance with paragraph (s)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (s) of this section.) (u) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Providers acts or omissions -4- arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses,costs, and expenses, including legal costs and attomeys'fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 DISCRIMINATION,TERMINATION,AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal,state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one(1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs,CA 92262-6959 Attn: City Manager -5- WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Shelter From The Storm, Inc. 73550 Alessandro Dr, Ste 103 Palm Desert, CA 92260-3613 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [ End—Signatures on Next Page] -6- CITY OF PALM SPRINGS ATTEST: municipal corporation Q, By: ity Clerk o-1 f 6 City Manager APPROV D 9 ISO FORM: APPROVED BY CITY COUNCIL B. / � a�1�yb ` �►� P�bbb6 City Attor ey PROVIDER: Check one: _Individual _Partnership Xcorporation (Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signature must be from the Secretary, Assistant S etary, Treas rer, sistant urer, or Chief Financial Officer). By: By: feria-.i Notarized Si atur irman of Board, Nefiri l ire Secretary,Asst Secretary, *Prelldanty Vice dent Treasurer,AssE Treasurer or Chief Financial Officer Nam ` Name: nE- rmTitle:State ) State of 1, n iQ ) County of vt.3i d as County of i V w "d t )as A notary public or other officer completing this certificate A notary public or other officer completing this cerUffoate verifies only the identity of the individual who signed the verifies only the Identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. State of u I1 0✓ a' ) State of / ",'f'- ) County of )ss. County of i >% £ )as. On Jzkylua t ! . ;?-a I I, before me, On V(.61 ua-Li I before me, � `��e12TH4 Vv 1bl.c,personally appeared ,(. jYj(1/iC"rjaltGf9 lyvb l iG personally appeared V • I to 5 J o d o f n who proved to -�Y✓C A K✓T who proved to me on the basis of satisfactory evidence to be the person(s) me on the ba of satisfactory evidence to be the person(rq) whose name(s)Is/ark subscribed to the within instrument and whose name(p)is/a94 subscribed to the within instrument and acknowledged to me that he/shaghey executed the same in acknowledged to me that he/shalitwy executed the same in histherAheir authorized capacity(ies), and that by histhediffor his/herNf191r authorized capacity(igs),and that by his/hep*wr signature(s) on the instrument the person(s) or the entity signature(dj on the Instrument the person(s), or the entry upon behalf of which the persons) acted, executed the upon behalf of which the person(a'l acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and correct correct. WITNESS my hand and official seal. WITNESS my hand and official seal Notary Signature: i GL Notary Signature: k Notary Seal: J STANCE Notary SeaCT --i COMM. #2052774 z e J. STAkGE o COMHt. #2052714 z a: iJotary Public California o Notary Public- California x' = Riverside County Riverside County o � M Comm.Expires Jan. 17,201B Comm. Ex Tres Jan. 17,2018 Dale=DBG1 S185Wm%Strm_SubrecipAgmnLALg15 - 7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Protect Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 Objectives/Activities The intent of this program is to provide case management services for domestic violence victims. This will be accomplished through the partial funding of a full-time bilingual Director of Programs Services at their Emergency Shelter. The staff will be the Advocates' role to provide identified victims with access to Shelter from the Storm's comprehensive range of domestic abuse services including emergency shelter, mental health counseling, case management, parenting skills training, independent living training, housing assistance, legal advocacy and linkage to health services for nineteen (19) battered spouses. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties (i.e., Provider, City. CDBG-Recovery, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective4: Enroll and income qualifies at least an approximately nineteen (19) residents in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming for Palm Springs residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 Monthly Submit semi-annual reports —referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31s', and program completion, June 301" Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination / EEO requirements. Objective 7: Provide emergency housing services, including motel vouchers to homeless individuals, as stipulated in this Agreement. TARGET DATE ACTIVITY#1 On-Going Conduct program activities, as stipulated in the proposal. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/16 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.). CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Activity Title: Project Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 ��i=I� I„T. �IGQAN�B..._ II COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel $7,500. $54,358. $61 ,858. 2 Consultant/Contract Services - 0 - - 0 - - 0 - 3 Travel - 0 - - 0 - - 0 - 4 Space Rental - 0 - - 0 - - 0 - 5 Consumable Supplies - 0 - - 0 - - 0 - 6 Rental, Lease or Purchase of - 0 - - 0 - - 0 - Equipment 7 Insurance - 0 - - 0 - - 0 - 8 Other - 0 - - 0 - - 0 - Telephone $7,500. $54,358. $61,858. TOTALS If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding, grantor/lending agency, and cost category information. Other funding sources primarily are fundraising activities conducted by Shelter From the Storm's auxiliary, State Grants, and Donations/Gifts, totaling $54,358. EXHIBIT B— Budget Summary Page 2 of 2 Pages DETAIL SLIME DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL PAY ITEMS SHARE SOURCES COST Personnel - $5,699. $9,886. $24,960. Salaries— Director of Program Services Benefits— Director of Program Services $1,801. $3,463. $8,759. Tvta4 _ $T $54,3.56 The Subrecipient shall submit monthly reimbursement of Personnel Salaries/Benefits for Director of Program Services, based on prorated salary and actual fringe benefits in accordance with the aforementioned cost categories. In no month shall the Subrecipient submit for reimbursement more than Y< of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the 301h day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2015-16 Program Year—July 1, 2015 through June 30, 2016. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/Activity Title: Project Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Philadelphia Insurance Companies Effective Dates of Policy 07/01/15 through 07/02/16 Claims Made Policy / / Per Occurrence Policy / / Limits of Liability General Aggregate $2 000,000 Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 04/01/16 through 04/01/17 Limits of Liability $1,000,000 Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes 21 No • -� SHELT-1 OP ID:AH ACIf7RO ATE(MMIDDFYYYY) CERTIFICATE OF LIABILITY INSURANCE D0710612016 07f06f2016 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 pollcy(les) must 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 endorsements. PRODUCER NAMEACT Hugh K.Curtis Curtis&Harris Insurance Sery PHOE AC Na: 619-303�994CA License 9 OF30715 C a PO Box 3129 A4WRESS:hugh@curtisharrisinsurance.com - - La Mesa, CA 91944 Hugh Curtis LNSURER(S)AFFORDING COVERAGE NAIC r INSuRERA:Phifallel hialnsuranceCo. 23850 INSURED Shelter from the Storm INSURERS:State Compensation Ins. Fund 35076 73-550 Alessandro#102-103 Palm Desert,CA 92260 INSURER C: INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION 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 TYPE OF INSURANCE LIMITS LTR S POLICY NUMBER MMIODIYYYY MMIDDM/YY A X COMMERCIAL GENERAL LIABILITY EACH 0 CCURR ENCE $ 1,000,00 CLAIMSMADE TOCCUR X X PHPK1515381 07/01/2016 07/01/2017 PREMISES Eacccurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY PRO- ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,00 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SIN SUE LIMIT $ 1,000,00 Ea accident A ANY AUTO PHPKI515381 07/0112016 07/01/2017 BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ X AUTOS AUTOS X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 1,000,00 A X EXCESS LMB CLAIMS MADE P14UB546348 07/01/2016 07/01/2017 AGGREGATE $ 1,000,00 DED X RETENTION$ 10,000 1 $ ri AND EMPLOYE RS'LOWERS COMPENSATION MBILITY X STATUTE ER B OFFICER/MEMBER ARC ER=UTIVE YINDED? NIA X 9078032.15 04/01/2016 04/01/2017 E.L.EACH ACCIDENT $ 1,000,00 (Mandatory In NHI EL DISEASE EAEMPLOYEE $ 1,000,00 Ifyes describe under DESCRIPTION OF OPERATIONS below EL DISEASE POLICYLI MIT $ 1,000,00 A Professional PHPK1515381 07/01/2016 07/0112017 Ea.Occ. 2,000,00 Liability Aggregate 2,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHCLES (ACORD 101,Addidonsl Remarks Schedule,may be attachadi M more space is required) The City of Palm Springs and their elected or appointed officers, am ployyees,aggents and volunteers are named as additional insured per attached orm PI-GLD-HS 10111 when required by a written contract.Waiver of subrogation applies per attached form CG24 04 10193 when required b.written contract. Primary wording applies when required by written contract. CERTIFICATE HOLDER CANCELLATION CITYOFP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. 3200 E.Tahquitz Canyon Way Palm Springs,CA 92262 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014f01) The ACORD name and logo are registered marks of ACORD NOTEPAD: HOLDER CODE CITYOFP SHELTA PAGE INsusrus NAME Shelter from the Storm OP ID:AH D9. 07/06/2016 aiver of subrogation for workers compensation insurance provided per attached form 10217 when required by a written contract. PI-GLD-HS (10111) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT: HUMAN SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms,conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this endorsement. For complete details on specific coverages,consult the policy contract wording. Coverage Applicable Limit of Insurance Page# Extended Property Damage Included 2 Limited Rental Lease Agreement Contractual Liability $50,000limit 2 Non-Owned Watercraft Less than 58 feet 2 Damage to Property You Own, Rent,or Occupy $30,000 limit 2 Damage to Premises Rented to You $1,000,000 3 HIPAA Clarification 4 Medical Payments $20,000 5 Medical Payments—Extended Reporting Period 3 years 5 Athletic Activities Amended 5 Supplementary Payments—Bail Bonds $5,000 5 Supplementary Payment—Loss of Earnings $1,000 per day 5 Employee Indemnification Defense Coverage $25,000 5 Key and Lock Replacement—Janitorial Services Client Coverage $10,000limit 6 Additional Insured —Newly Acquired Time Period Amended 6 Additional Insured —Medical Directors and Administrators Included 7 Additional Insured —Managers and Supervisors (with Fellow Included 7 Employee Coverage) Additional Insured —Broadened Named Insured Included 7 Additional Insured —FundingSource Included 7 Additional Insured —Home Care Providers Included 7 Additional Insured —Managers, Landlords, or Lessors of Premises I ncluded 7 Additional Insured—Lessor of Leased Equipment Included 7 Additional Insured —Grantor of Permits Included 8 Additional Insured—Vendor Included 8 Additional Insured—Franchisor Included 9 Additional Insured —When Required by Contract Included 9 Additional Insured —Owners, Lessees, or Contractors Included 9 Additional Insured —State or Political Subdivisions Included 10 Page 1 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ©2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Duties in the Event of Occurrence, Claim or Suit Included 10 Unintentional Failure to Disclose Hazards Included 10 Transfer of Rights of Recovery Against Others To Us Clarification 10 Liberalization Included 11 Bodily Injury—includes Mental Ang uish Included 11 Personal and Advertising Injury—includes Abuse of Process, Included 11 Discrimination A. Extended Property Damage SECTION I —COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph a. is deleted in its entirety and replaced by the following: a. Expected or Intended Injury "Bodily injury"or property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to"bodily injury"or"property damage" resulting from the use of reasonable force to protect persons or property. B. Limited Rental Lease Agreement Contractual Liability SECTION I—COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph b. Contractual Liability is amended to include the following: (3) Based on the named insured's request at the time of claim, we agree to indemnify the named insured for their liability assumed in a contract or agreement regarding the rental or lease of a premises on behalf of their client, up to$50,000. This coverage extension only applies to rental lease agreements. This coverage is excess over any renters liability insurance of the client. C. Non-Owned Watercraft SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph g. (2)is deleted in its entirety and replaced by the following: (2) A watercraft you do not own that is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. D. Damage to Property You Own, Rent or Occupy SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE Page 2 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ©2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) LIABILITY, Subsection 2. Exclusions, Paragraph j. Damage to Property, Item (1) is deleted in its entirety and replaced with the following: (1) Property you own, rent, or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property, unless the damage to property is caused by your client, up to a$30,000 limit. A client is defined as a person under your direct care and supervision. E. Damage to Premises Rented to You 1. If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word"fire"is changed to"fire, lightning, explosion, smoke, or leakage from automatic fire protective systems"where it appears in: a. The last paragraph of SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions; is deleted in its entirety and replaced by the following: Exclusions c.through n. do not apply to damage by fire, lightning, explosion, smoke, or leakage from automatic fire protective systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in SECTION III—LIMITS OF INSURANCE. b. SECTION III—LIMITS OF INSURANCE, Paragraph 6. is deleted in its entirety and replaced by the following: Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the mostwe will pay under Coverage A for damages because of"property damage"to any one premises, while rented to you, or in the case of damage by fire, lightning, explosion, smoke,or leakage from automatic fire protective systems while rented to you or temporarily occupied by you with permission of the owner. c. SECTION V—DEFINITIONS, Paragraph 9.a., is deleted in its entirety and replaced by the following: A contractfor a lease of premises. However, that portion of the contractfor a lease of premises that indemnities any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protective systems to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract"; 2. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance, Paragraph b. Excess Insurance;(1) (a) (ii) is deleted in its entirety and replaced by the following: That is insurance for fire, lightning, explosion, smoke, or leakage from automatic.fire protective systems for premises rented to you or temporarily occupied by you with permission of the owner; 3. The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater of: Page 3 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) a. $1,000,000, or b. The amount shown in the Declarations as the Damage to Premises Rented to You Limit. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. F. HIPAA SECTION I—COVERAGES, COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY, is amended as follows: 1. Paragraph 1. Insuring Agreement is amended to include the following: We will pay those sums that the insured becomes legally obligated to pay as damages because of a"violation(s)"of the Health Insurance Portability and Accountability Act(HIPAA). We have the right and the duty to defend the insured against any"suit," "investigation,"or"civil proceeding" seeking these damages. However, we will have no duty to defend the insured against any"suit" seeking damages, "investigation,"or"civil proceeding" to which this insurance does not apply. 2. Paragraph 2. Exclusions is amended to include the following additional exclusions: This insurance does not apply to: a. Intentional, Willful, or Deliberate Violations Any willful, intentional, or deliberate"violation(s)" by any insured. b. Criminal Acts Any"violation"which results in any criminal penalties under the HIPAA c. Other Remedies Any remedy other than monetary damages for penalties assessed. d. Compliance Reviews or Audits Any compliance reviews by the Department of Health and Human Services, 3. SECTION V—DEFINITIONS is amended to include the following additional definitions: a. "Civil proceeding" means an action by the Department of Health and Human Services (HHS) arising out of"violations." b. "Investigation" means an examination of an actual or alleged "violation(s)" by HHS. However, "investigation"does not include a Compliance Review. c. "Violation" means the actual or alleged failure to comply with the regulations included in the HIPAA. Page 4 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) G. Medical Payments—Limit Increased to$20,000, Extended Reporting Period If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit is changed subject to all of the terms of SECTION III -LIMITS OF INSURANCE to the greater of: a. $20,000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. SECTION I—COVERAGE, COVERAGE C MEDICAL PAYMENTS, Subsection 1. Insuring Agreement, a. (3) (b) is deleted in its entirety and replaced by the following: (b) The expenses are incurred and reported to us within three years of the date of the accident. H. Athletic Activities SECTION I—COVERAGES, COVERAGE C MEDICAL PAYMENTS, Subsection 2. Exclusions, Paragraph e. Athletic Activities is deleted in its entirety and replaced with the following: e. Athletic Activities To a person injured while taking part in athletics. I. Supplementary Payments SECTION I—COVERAGES, SUPPLEMENTARY PAYMENTS -COVERAGE A AND B are amended as follows: 1. b. is deleted in its entirety and replaced by the following: 1. b. Up to $5000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these. 1.d. is deleted in its entirety and replaced by the following: 1. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit', including actual loss of earnings up to$1,000 a day because of time off from work. J. Employee Indemnification Defense Coverage SECTION I—COVERAGES,SUPPLEMENTARY PAYMENTS—COVERAGES A AND B the following is added: We will pay, on your behalf, defense costs incurred by an `employee" in a criminal proceeding occurring in the course of employment. The most we will pay for any"employee"who is alleged to be directly involved in a criminal proceeding is$25,000 regardless of the numbers of"employees," claims or"suits" brought or persons or organizations making claims or bringing "suits. Page 5 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ®2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) K. Key and Lock Replacement—Janitorial Services Client Coverage SECTION I—COVERAGES, SUPPLEMENTARY PAYMENTS—COVERAGES A AND B is amended to include the following: We will pay for the cost to replace keys and locks at the"clients" premises due to theft or other loss to keys entrusted to you by your"client," up to a $10,000 limit per occurrence and $10,000 policy aggregate. We will not pay for loss or damage resulting from theft or any other dishonest or criminal act that you or any of your partners, members, officers, "employees", "managers", directors,trustees, authorized representatives or any one to whom you entrust the keys of a"client"for any purpose commit,whether acting alone or in collusion with other persons. The following, when used on this coverage, are defined as follows: a. "Client'means an individual, company or organization with whom you have a written contract or work order for your services for a described premises and have billed for your services. b. "Employee"means: (1) Any natural person: (a) While in your service or for 30 days after termination of service; (b) Who you compensate directly by salary, wages or commissions,and (c) Who you have the right to direct and control while performing services for you; or (2) Any natural person who is furnished temporarily to you: (a) To substitute for a permanent"employee"as defined in Paragraph (1)above, who is on leave; or (b) To meet seasonal or short-term workload conditions, while that person is subject to your direction and control and performing services for you. (3) "Employee"does not mean: (a) Any agent, broker, person leased to you by a labor leasing firm, factor, commission merchant, consignee, independent contractor or representative of the same general character; or (b) Any"manager,"director or trustee except while performing acts coming within the scope of the usual duties of an "employee" c. "Manager"means a person serving in a directorial capacity for a limited liability company. L. Additional Insureds SECTION II—WHO IS AN INSURED is amended as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Page 6 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 0 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) Coverage Part, Paragraph 3.a. is deleted in its entirely and replaced by the foliowing: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. Medical Directors and Administrators—Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. b. Managers and Supervisors—Your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. Managers and supervisors who are your"employees" are also insureds for"bodily injury'to a co- .employee"while in the course of his or her employment by you or performing duties related to the conduct of your business. This provision does not change Item 2.a.(1)(a)as it applies to managers of a limited liability company. c. Broadened Named Insured —Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance. d. Funding Source—Any person or organization with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Home Care Providers—At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled. f. Managers, Landlords, or Lessors of Premises—Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased or rented to you subject to the following additional exclusions: This insurance does not apply to: (1) Any"occurrence"which takes place after you cease to be a tenant in that premises, or (2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. g. Lessor of Leased Equipment—Automatic Status When Required in Lease Agreement With You —Any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization is to be added as an additional insured on your policy. Such person or Page 7 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 0 2011 Philadelphia Indemnity Insurance Company PI-GILD-HS (10111) organization is an insured only with respect to liability for"bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. A person's or organization's status as an additional insured under this endorsement ends when their contractor agreement with you for such leased equipment ends. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any"occurrence"which takes place after the equipment lease expires. h. Grantors of Permits —Any state or political subdivision granting you a permit in connection with your premises subject to the following additional provision: (1) This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with the premises you own, rent or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs,awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; (b) The construction, erection, or removal of elevators, or (c) The ownership, maintenance, or use of any elevators covered by this insurance. L Vendors —Onlywith respect to injury" or"property damage"arising out of"your P Y 9 9 Y products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: (1) The insurance afforded the vendor does not apply to: (a) "Bodily injury"or"property damage"for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contractor agreement; (b) Any express warranty unauthorized by you, (c) Any physical or chemical change in the product made intentionally by the vendor, (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container, (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; Page 8 of 12 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. 0 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor, or (h) 'Bodily injury"or"property damage"arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (i) The exceptions contained in Sub-paragraphs(d)or(f);or (it) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing. j. Franchisor—Any person or organization with respect to their liability as the grantor of a franchise to you. k. As Required by Contract—Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for"bodily injury,""property damage"or "personal and advertising injury" but only for liability arising out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are included within and not in addition to the limits of insurance shown in the Declarations I. Owners, Lessees or Contractors—Any person or organization, 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 when required by a contract. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to"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. Page 9 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ©2011 Philadelphia Indemnity Insurance Company • PI-GLD-HS (10111) m. State or Political Subdivisions—Any state or political subdivision as required, subject to the following provisions: (1) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit, and is required by contract. (2) This insurance does not apply to: (a) 'Bodily injury,""property damage" or"personal and advertising injury"arising out of operations performed for the state or municipality, or (b) 'Bodily injury"or"property damage" included within the"products-completed operations hazard." M. Duties in the Event of Occurrence, Claim or Suit SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 2, is amended as follows: a. is amended to include: This condition applies only when the"occurrence" or offense is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership, or (3) An executive officer or insurance manager, if you are a corporation. b. is amended to include: This condition will not be considered breached unless the breach occurs after such claim or"suit" is known to: (1) You, if you are an individual, (2) A partner, if you are a partnership, or (3) An executive officer or insurance manager, if you are a corporation. N. Unintentional Failure To Disclose Hazards SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS,6. Representations is amended to include the following: It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. O. Transfer of Rights of Recovery Against Others To Us SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer of Rights of Page 10 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 0 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Recovery Against Others To Us is deleted in its entirety and replaced by the following: If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit"or transfer those rights to us and help us enforce them. Therefore, the insured can waive the insurer's rights of recovery prior to the occurrence of a loss, provided the waiver is made in a written contract. P. Liberalization SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, is amended to include the following: If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. Q. Bodily Injury—Mental Anguish SECTION V—DEFINITIONS, Paragraph 3. Is deleted in its entirety and replaced by the following: "Bodily injury" means: a. Bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these, and b. Exceptfor mental anguish, includes death resulting from the foregoing (Item a.above) at any time. R. Personal and Advertising Injury—Abuse of Process, Discrimination If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise excluded from this Coverage Part, the definition of"personal and advertising injury" is amended as follows: 1. SECTION V—DEFINITIONS, Paragraph 14.b. is deleted in its entirety and replaced by the following: b. Malicious prosecution or abuse of process; 2. SECTION V—DEFINITIONS, Paragraph 14. is amended by adding the fallowing: Discrimination based on race, color, religion, sex, age or national origin, except when: a. Done intentionally by or at the direction of, or with the knowledge or consent of: (1) Any insured; or (2) Any executive officer, director, stockholder, partner or member of the insured; b. Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured, Page 11 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 0 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) c. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental, lease or sub-lease of any room,dwelling or premises by or at the direction of any insured, or d. Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation,court decision or administrative ruling. The above does not apply to fines or penalties imposed because of discrimination. Page 12 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 0 2011 Philadelphia Indemnity Insurance Company POLICY NUMBER: PHPK1515381 COMMERCIAL GENERAL LIABILITY CG 2404 1093 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization to which you are obligated by virtue of written contract to provide insurance such as is afforded by this policy, but only with respect to (1) occurrences taking place after such written contract has been executed and (2) occurrences resulting from work performed by you during the policy period,or occurrences resulting from the conduct of your business during the policy period. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work" done under a contract with that person or organization and included in the "products-completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 i . ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 02 BLANKET BASIS 9078032-16 RENEWAL HOME OFFICE SP SAN FRANCISCO EFFECTIVE APRIL 1, 2016 AT 12.01 A.M. 4-61-14-20 PAGE 1 OF ALL EFFECTIVE DATES ARE AND EEPIRIHG APRIL 1, 2017 AT 12.01 A.M. 1 AT 1201 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SHELTER FROM THE STORM, INC. 73550 ALESSANDRO DRIVE #102, 103 & 104 PALM DESERT, CA 92260 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`00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAANNFRFRANCISCJO. MARCH 30, 2016 AUTHORIZED REPRESENT iVE PRESIDENT AND CEO 2572 SMF FORM 10217 REV.?-20141 OLD OR 217 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described projectlactivity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA-03106115) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL-$60,500 EXTREMELY LOW INCOME $13.100 $15,930 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 0 30%of AMI LOW INCOME $21,750 $24,850 $27,950 $31,050 $33,550 $36,050 $38,550 $41,000 30-50%of AMI MODERATE INCOME $34,800 $39,800 $44,750 $49,700 $53,700 $57,700 $61,650 $65,650 50-80%of AMI NON LOW 8 MOD INCOME $34,801 $39,801 $44,750 $49,701 $53,701 $57,701 $61,651 $65.651 >80% 3. What race/ethnicity do you identify yourself as; please note that this self-identification is voluntary in accordance with equal opportunity laws? ❑ White ❑ American Indian or Alaska Native AND White ❑ Black/African American ❑ Asian AND White ❑ Asian ❑ Black/African American AND White ❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/African American ❑ Native Hawaiian or Other Pacific Islander ❑ Other: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: ❑ Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Are you female Head of Household? ❑ YES ❑ NO 5. Do you have a disability? ❑ YES ❑ NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes, a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Project Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons <or=30%: 30-50%: 50-80%: > 80%: • Number of First-Time Female Headed Households: • Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White Amercan Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPAMOLATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: • Number of Disabled: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Shelter From The Strom / 0009 Client Case Management Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. 103 Palm Desert, CA 92260-3613 BENEFICIARY QUALIFICATION STATEMENT [j�( ,�, �) 4. . . .. :. .._ ... .._.. ...:... ( I4I1 ° i'I i. IIlU1 dI Salaries-Director of Program Services $5,699.00 Benefits-Director of Program Services $1,801.00 I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b)funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary, additional sheet(s) must be attached detailing cost breakdowns, and verified by original signatures.