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A2017--017 <br />Services Agreement <br />Below you will find a checklist relating to Insurance and other requirements that are required for doing business with the City of Chino Hills. <br />Only those items checked -off are MANDATORY, however if your standard policies exceed the minimum requirements please include. <br />Commercial general liability insurance must meet or exceed the requirements of ISO -CGL Form No. CG 00 01 1185 or 88. The <br />amount of insurance set forth below will be a combined single limit per occurrence for bodily injury, personal injury, and <br />property damage for the policy coverage. Liability policies will be endorsed to name the City, its officials, and employees as <br />"additional insured's" under said insurance coverage and to state that such insurance will be deemed "primary" such that any <br />other insurance that may be carried by the City will be excess thereto. Workers' Compensation policies shall waive all rights of <br />subrogation against City, its officers, officials, employees and agents for losses arising from work performed by Consultant for <br />City. Such insurance must be on an "occurrence," not a "claims made," basis and will not be cancelable or subject to reduction <br />except upon thirty (30) days prior written notice to the City. Please find additional Terms and Conditions on the reverse side of this <br />Services Agreement. This is not a Contract order or an authorization to begin work. <br />® Comprehensive General Liability, including coverage for premises, products and completed operations, independent contractors, <br />personal injury and contractual obligations with combined single limits of coverage of at least $1,000,000 per occurrence. The <br />City of Chino Hills is to be listed as an additionally insured party. <br />® Auto Liability, including owned, non -owned and hired vehicles with at least: <br />® $1,000,000 per occurrence. <br />❑ $100,000 - 300,000 per occurrence. <br />❑ As required by State Statutes. A copy of your current policy must be submitted naming yourself and or your company, <br />® Workers' Compensation Insurance: as required by State Statutes including Waiver of Subrogation. (Not needed if Self-employed <br />with no employees and CONTRACTOR signs statement to this effect.) <br />❑ Business License: The SERVICE PROVIDER shall agree to have a current City of Chino Hills license on file at City Hall or <br />purchase said license (at no cost to the City). <br />® Scope of Services and/or Compensation Attachments <br />❑ Total Annual Compensation Nat -to -Exceed: <br />® Total Compensation Not -to -Exceed: $ 774.20 <br />® Expiration Date: Januaryl- 2016 February 28, 2017 <br />PLEASE NOTE: ALL APPLICABLE INFORMATION LISTED ABOVE MUST BE OBTAINED AND ON FILE, PRIOR TO THE ISSUANCE OF A CITY <br />CONTRACT BEING SENT TO YOU (VIA FAX OR HARD COPY) BY THE CONTRACT COMPLIANCE OFFICER, THUS AUTHORIZING COMMENCEMENT <br />OF WORK FOR THE CITY. AGREEMENT IS EFFECTIVE AS OF DATE LAST SIGNED BELOW. <br />Company Name: <br />By (Print name & title): <br />A&C Billiards & Barstools <br />Cathy Van Alstine <br />Company Mailing Address: <br />City, State, Zip: <br />18605 E. Gale Avenue #3 <br />City of Industry, CA 91748 <br />Phone: <br />E -Mail Address: <br />626) 810-1388 <br /> <br />Mail two copies of the original agreement along with proof of insurance to: City of Chino Hills - City Clerk,14000 City Center Drive, Chino Hills, CA 91709 <br />OriginatorlDepariment Contact <br />Vendor's Authorized Signature <br />Vendor's Authorized Signature <br />Contract Compliance Approval <br />Department Director/City Manc <br />Date initiated: 1216/2016 <br />]ate signed: VaLlel <br />Date signed: <br />Date Approved: <br />Date Approved: i 7 <br />