1.H AMEND NO. 2 WITH OCY MANAGEMENT LLC FOR SENIOR TRANSPORTATION SERVICES

Agenda Item No: 1.h

PLACENTIA CITY COUNCIL AGENDA REPORT
Meeting Date: May 19, 2026
Submitted by: Lydie Gutfeld
From: Community Services
Subject:

AMENDMENT NO. 2 TO THE PROFESSIONAL SERVICES AGREEMENT WITH OCY

MANAGEMENT, LLC
Financial Impact:
20% Match from General Fund (101-30603-6315) $18,743
OCTA Measure M Funding_ (211-30000-6315) $74.972
BUDGET $93,715
Summary:

The City of Placentia has partnered with OCYM to provide senior transportation services through the Senior Mobility Program (SMP). Amendment No. 1, approved by the City Council on June 17, 2025, authorized the first of three one-year extensions to the agreement and reflected a company name change.

Staff now recommends approval of Amendment No. 2 to authorize the second one-year extension in an amount not to exceed $93,715. This amendment also includes an additional 13 days, extending the contract term through June 30 to align with the Orange County Transportation Authority grant funding cycle.

Recommended Action:

It is recommended that the City Council:

1. Approve Amendment No. 2 to a Professional Services Agreement with OCY Management, LLC (OCYM) to extend the grant agreement period with a one-year extension, in a total amount not to exceed $93,715 to continue providing senior transportation services; and

2. Authorize the City Administrator and/or her designee to execute all necessary documents, in a form approved by the City Attorney; and

3. Authorize the City Administrator to approve the eligible agreement term extension based upon contractor performance and at the discretion of the City.

Strategic Plan Statement:

This item supports Strategic Plan Goal No. 1: Fiscal Sustainability. The program is primarily funded through the Orange County Transportation Authority (OCTA) (80%), with only a 20% contribution from the City's General Fund, demonstrating fiscal responsibility by leveraging external funding to deliver essential services.
1 Discussion:

The City currently maintains an agreement with OCYM to provide transportation services for senior residents. OCYM has delivered these services reliably, and the program remains the most utilized transportation option within the senior community.

The Senior Mobility Program (SMP) provides transportation to and from the Placentia Senior Center, Monday through Friday, for Placentia senior residents. In addition, the program offers trips to five predetermined destinations twice per week (Tuesdays and Thursdays), including medical offices, grocery stores, pharmacies, and other essential businesses that support residents' daily needs.

The SMP is funded through a grant agreement with the Orange County Transportation Authority (OCTA), which covers 80% of the program's annual operating costs. The remaining 20% local match is funded by the City's General Fund.

Amendment No. 2 would extend the current agreement for OCYM to continue providing services without interruption. Extending the agreement helps avoid any gaps in service and allows the City to keep working with a provider that is already familiar with the program and its participants. Due to OCTA's commitment to funding the next four (4) years for transportation, Staff recommends continuing this agreement and supporting the City's goal of helping seniors remain active, safe, and connected in the community.

Financial Summary:

There is no increase to the overall not -to -exceed amount; services will continue to be funded through the existing grant allocation of (FY27-28), $74,972. Under this agreement, the City of Placentia will continue to use these funds in addition to the 20% city match of $18,743 (101- 30603-6315) to provide transportation services to seniors.

Attachments
Amendment 2 OCYM-Professional Services.pdf
OCY Management LLC - Amendment No. 1 Sr. Transportation.pdf 2 AMENDMENT NO. 2 TO

PROFESSIONAL SERVICES AGREEMENT

PROVISION OF PROFESSIONAL SERVICES WITH OCY MANAGEMENT, LLC This Amendment No. 2 ("Amendment") to the Professional Services Agreement is made and entered into effective the 30th day of June 2026, by and between the CITY OF PLACENTIA, a Charter City and Municipal Corporation ("CITY"), and OCY MANAGEMENT, LLC (OCYM), a California corporation (hereinafter "CONSULTANT"). CITY and CONSULTANT are sometimes hereinafter individually referred to as "Party" and or collectively referred to as the "Parties."
A. Recitals.
(i). CITY and CONSULTANT entered into a Professional Services Agreement ("Agreement") effective June 17, 2025, through which CONSULTANT has been providing professional services as more fully explained in the Scope of Services attached to the Agreement as Exhibit "A."
(ii). The Parties now seek to amend the Agreement to extend the term of the contract for one year and maintain compensation not to exceed $93,715. (iii). All legal prerequisites to the making of this Amendment have occurred.

NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, the Parties agree as follows:

B. Amendment to Agreement.

1. Article B, paragraph 4.1 of the Agreement is hereby amended to read as follows:

Extend the term of the contract for an additional period of twelve (12) months, commencing June 30, 2026, through June 30, 2027, with total compensation not to exceed $93,715.

2. Except as specifically modified herein, all of the terms, conditions and provisions of the Agreement shall remain in full force and effect.

3. The Agreement, all amendments together with this Amendment No. 2 and all Exhibits attached thereto, constitutes the entire Agreement between the Parties and supersedes all prior negotiations, arrangements, representations, and understandings, if any, made by or between the Parties with respect to the subject matter hereof. No amendment or other modification of the Agreement, as modified by this Amendment No.1, shall be binding unless executed in writing by both Parties hereto, or their respective successors, assigns, or grantees.

4. Each of the undersigned represents and warrants that he or she is duly authorized to execute and deliver this Amendment No. 2 and that such execution is binding upon the entity for which he or she is executing this document.

Page 1 of 2 ends

3 IN WITNESS WHEREOF, the Parties have caused Amendment No. 2 to the Consulting Services Agreement are to be executed as of the day and year first above written.

CONSULTANT
By: /
Akbar Majid, President

CITY OF PLACENTIA
By:

Jennifer Lampman, City Administrator
ATTEST:

By:

Robert S. McKinnell, City Clerk
APPROVED AS TO FORM:

By:

Page 2 of 2 ends

Christian L. Bettenhausen, City Attorney
4 AMENDMENT NO. 1 TO

PROFESSIONAL SERVICES AGREEMENT

PROVISION OF SENIOR TRANSPORTATION SERVICES WITH OCY MANAGEMNET, LLC (OCYM)
This Amendment No. 1 ("Amendment") to Professional Services Agreement is made and entered into effective the 17 day of June, 2025, by and between the CITY OF PLACENTIA, a Charter City and Municipal Corporation ("CITY"), and OCY Management, LLC, a California corporation (hereinafter "CONSULTANT"). CITY and CONSULTANT are sometimes hereinafter individually referred to as "Party" and or collectively referred to as the "Parties." A. Recitals.
(i) CITY and CONSULTANT entered into a Professional Services Agreement ("Agreement") effective April 3, 2023 through which CONSULTANT has been providing professional services as more fully explained in the Scope of Services attached to the Agreement as Exhibit "A".
(ii) The Parties now seek to amend the Agreement to extend the term of the contract and set a new compensation not to exceed $165,340.60.
(iii) All legal prerequisites to the making of this Amendment have occurred.

NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, the Parties agree as follows:

B. Amendment to Agreement.

1. Section 2A and 4.1, Paragraph 1 of the Agreement is hereby amended to read as follows:

2.1 Compensation. Consultant shall be paid in accordance with the fee schedule set forth in Exhibit "A". Consultant's total compensation shall not exceed $165,340.60 for the one-year extension.

4.1 Term. This Amendment No. 1 shall commence on the Effective Date and continue for a period of 12 months, ending on June 17, 2026.

2. Except as specifically modified herein, all of the terms, conditions and provisions of the Agreement shall remain in full force and effect.

3. The Agreement, all amendments together with this Amendment No. 1 and all Exhibits attached thereto, constitutes the entire Agreement between the Parties and supersedes all prior negotiations, arrangements, representations, and understandings, if any, made by or between the Parties with respect to the subject matter hereof. No amendment or other modification of the Agreement, as modified by this Amendment No. 1 shall be binding unless executed in writing by both Parties hereto, or their respective successors, assigns, or grantees.

4. Each of the undersigned represents and warrants that he or she is duly authorized to execute and deliver this Amendment No. 1 and that such execution is binding upon the entity for which he or she is executing this document.

Page 1 of 2 ends

IN WITNESS WHEREOF, the Parties have caused Amendment No. 1 to the Consulting Services Agreement are to be executed as of the day and year first above written.

CONSULTANT CITY OF PLACENTIA
By:

Maar r A��
Akbar Majid, President
By:

K n Irwin, Mayor
ATTEST:

By:

Robert S. McKinnell, City Clerk

APPROVED AS TO FORM-)
Christian L. Bettenhausen, City Attorney

Page 2 ends

Senior Mobility Program
City of Placentia
January 1, 2023

CO
Table of Contents
Tab #1
Letter of Transmittal 4
Company Summary 5
Key Personnel 7
Scope of Work & Proposed Operational System 13
Experience 24
Tab#2
Equipment/Safety Violations 27
Tab #3
CHP Safety Compliance Report 3
Tab #4
Reference Form (Exhibit G) 3
Tab #5
Proposal Form Exhibit H 3
2 TAB #1

California Yellow Cab
520 West Dyer Road Santa Ana, California 92707
714.427.2555 www.CaliforniaYellowCao.com
(714)444-4444 (949)444-4444
Felipe Zambrano, Community Services Coordinator
City of Placentia
401 E Chapman Ave,
Placentia, CA 92870
Hello Mr. Zambrano,
(657)444-4444
January 1, 2023
Cabco Yellow Inc., dba California Yellow Cab (CYC) would kindly like to express interest in providing transportation services to the City of Placentia. The proposal shall remain valid for a period of not less than 180 days from the date of submittal.

In business since 1995, CYC has a long history of providing transportation services that go far beyond the traditional forms of taxicab services. Early in the company's history, we identified underserved segments of Orange County's population and sought to craft an on -demand service option for those affected by the challenges of public transportation. Today, CYC remains the largest and most adaptive taxicab fleet in the county, providing seniors and paratransit passengers the opportunity to get where they need to go, without doing so according to a bus schedule.

We are confident that at CYC we have the dedicated drivers and representatives to complete all tasks. In addition, our drivers not only are professional, but they will treat seniors with respect, help them in and out of the vehicle if permitted, have patience, and drive cautiously at all times.

Currently, we are contractors to numerous senior transportation programs in the county including the City of Fullerton, Cypress, La Habra, Fountain Valley, Laguna Woods, San Clemente, Laguna Hills, Orange, Yorba Linda, Garden Grove, Laguna Niguel and others.

CYC is delighted to have the opportunity to submit this Proposal to you and we welcome the opportunity to continue to meet the transportation needs of seniors in your fine City.

Sincerely,
Tim Conlon
President
520 W Dyer Road, Santa Ana, CA 92707
T714.427.2555 X112
tconloncayellow.com
4 Company Summary
Legal Name of Company:

Cabco Yellow, Inc.

Dba Name of Company:

California Yellow Cab
520 W. Dyer Road
Santa Ana, Ca 92707
www.CaliforniaYellowCab.com
Dispatch Phone Numbers:
(714)444-4444
(949)444-4444
(657)444-4444
(877)935-5692
Name and Title of Person Completing Proposal: Tim Conlon, President P (714)427-2555 Ext. 112
F (714)438-0405
tconlonna.cavellow.com
Employer Identification Number:
33-0723354
Statement of Ownership:

Cabco Yellow, Inc. is a California S -Corp,
Wholly owned by William Rouse

Years in Business:

Since 1995; 25+ years
Failures or Refusals to Complete Any Contracts:

None
Arbitrations, lawsuits, settlements, etc. in the last 5 years There is no pending litigation or arbitration for Cabco Yellow Inc. other than that related to normal operational vehicle accident activity which has resulted in routine litigation, which is being addressed by our company's insurance carrier. Additionally, there are no other conditions — including those identified above — that Cabco Yellow believes would impede on the company's ability to service the program.

Financial Interests in Other Lines of Business:

DriveU San Diego, Long Beach Yellow Cab, Administrative Services Company Orange County Taxi Administration Program (OCTAP) Permit:
#17

Key Personnel
Tim Conlon- Mr. Conlon had served as the General Manager responsible for the day-to-day operations of California Yellow Cab (CYC) since the company's inception in 1995. As the company's current President, Mr.

Conlon's responsibilities include supervision of mechanical staff, vehicle inspections, securing proper vehicle permits and registrations, and administering risk management functions. Mr. Conlon has a bachelor's degree from California Polytechnic University and will remain the primary contact for the City of Placentia with a high commitment for this assignment, available throughout the program's duration.

Melissa Gomez- As the Director of Marketing since January 2017, Ms.

Gomez is responsible for ensuring our company meets program guidelines and outcome objectives according to the highest standards of service. Ms.

Gomez is also the Program Manager managing existing relationships and leading in handling service issues and/or complaint resolutions relevant to the programs in Orange County. Ms. Gomez has a long history in the transportation sector as a Project Manager ensuring seniors receive the best service possible and are transported in a safe and timely manner. Ms.

Gomez received a Bachelor's degree from California State University San Bernardino and Master's degree in Communications from California Baptist University.

California Yellow Cab Kev Personnel
William Rous
\lavaging
Partner/ CCE(?
'Tim Conlon
Pre9dent
Ruhrrt l 1 •6t E I t
Revua Chavrr
Accounting
C'Irrk
Mel) aa (ignicz
1ro:yam \3anacci
r)irrrMr of \1.111run�
Reyna Chavez
Acenuntinz Clerk
jonatan Martin
Driver/fleet
Manager
[3nhhinz `v.uven Urtct:r
Coordntan,r
Key Personnel Statement: President Tim Conlon, Director of Marketing/Program Manager Melissa Gomez, and Driver Manager Jonatan Martin will be available to the extent proposed for the duration of the project and acknowledge that no person designated as "key" to the project shall be removed or replaced without the prior written concurrence of the City. s

TIMOTHY CONLON
President
EDUCATION Mount San Antonio College
California Polytechnic University, Pomona
PROFESSIONAL California Yellow Cab, 1996 to Present
President / General Manager responsible for the day-to-day operations of the Company including driver hiring and training, supervision of mechanical staff, vehicle inspections, securing proper vehicle permits and registrations, administering risk management functions.

West Coast Transportation Network, 1994-1996
Series of progressively responsible positions from, dispatcher, accident investigator, office manager, general manager.

GMS Imports, 1990-1994
Regional Sales Manager for a furniture importer for the Western United States. Responsible for merchandising and marketing new lines and implementing and conducting sales training for affiliates.

Conlon Tire, Inc., 1972-1990
President and General Manager of family owned business until sold in 1990. Series of progressively responsible positions including, marketing

and advertising director, merchandising coordinator, customer service and human resources director.

AFFILIATIONS Santa Ana Chamber of Commerce
ACHIEVMENTS Newport Beach Chamber of Commerce
AWARDS Lions International, Past Committee Chairperson
While Cabco Yellow Inc. will utilize over 150 independent contractor drivers and our experienced call center staff for the day to day operations of this program, it will be the responsibility of the President, Tim Conlon, with help of Program Manager, Melissa Gomez to coordinate these efforts. Mr. Conlon will communicate with City staff regarding complaint resolutions, accident investigations, and any other issues or concems relevant to the success of this program. Tim Conlon will bring over (15) years of passenger transportation experience in Orange County to this program. Mr. Conlon has been the primary contact for several similar programs, including the OCTA — Senior Nutrition Program and Senior Dial a Taxi Program. This experience, coupled with a sincere desire to serve this segment of the County's population will make him an excellent manager of this program

MELISSA GOMEZ
Riverside, CA • 951-255-4367 ■ [email protected]
EDUCATION Riverside City College, 2009
California State University San Bernardino, 2014
California Baptist University, 2016
PROFESSIONAL California Yellow Cab, January 2017 to Present Director of Marketing and Program Manager who drives company through innovative strategic planning, interactive marketing, and sales promotion.

In addition to being Marketing Director also the Program Manager that ensures all program guidelines are being met, passengers are transported at a timely and safely manner and ensures there are high levels of customer service being emphasized. Skilled at analyzing customer needs to develop high standard customer service and problem solver who adapts to change and exceeds expectations under any circumstances. Ms. Gomez currently oversees all our senior mobility programs along with many other private and public programs throughout Orange County.

Mission Inn Foundation, August 2016- December 2016
Intern: Oversaw the planning and execution of logistics and operations for events through private meetings and conferences. Worked with event sponsors and vendors on all aspects of planning events. Assisted in

achieving business objectives with demanding timeframes and negotiated contracts with vendors and service providers.

Happy Taxi, February 2012- January 2017
Supervising Dispatcher and Paratransit Driver
When starting with Happy Taxi answered routine employee and recruitment related questions such as appropriate documentation submission and application status. Assisted in scheduling interviews and training times/dates for candidates. Provided training and orientation for new staff and routed customer orders in a timely manner. When needed would transport seniors or paratransit members to and from their residence to senior centers, medical, shopping, and/or personal appointments. Also, generated invoices and responded to customers with inquiries and/or complaints.

Scope of Work & Proposed Operational System for
City of Placentia
California Yellow Cab - CYC - proposes to establish a toll-free telephone number for use by the Senior Mobility Program (SMP) patrons in the City of Placentia. By using this number, program participants may call for on -demand service with the expectation of a cab arriving at the pick-up address within sixty (60) minutes, during program service hours. The phone number will automatically identify the caller as a program participant, and the participant would then only need to provide basic trip information along with their SMP I.D. number.

In addition to routine on -demand service, program participants may use the same phone number with the same identifying protocols for reservation service when possible, up to two weeks in advance. This can provide CYC dispatch with the ability to pre -route these trips to select drivers.

Reporting and Billing
Documentation and reporting on the part of CYC is managed via our proprietary digital - dispatch system. In addition to monthly trip data and invoicing, highly detailed electronic records are kept in our archiving, and can be accessed and placed into a report in as little as twenty-four hours. Information submitted, stored and readily available for any reporting purposes include rudimentary dispatch data like passengers' names, pick-up locations, destinations, dates and times of travel, passenger ID number, and additional contact information. Additionally, this data includes GPS "ping"

information from the cabs themselves that provide accurate data on the route taken during a trip, vehicle speed, performance standards data, records of customer contact including audio recordings of every call to or from a customer, and event records for each trip like times of pickups and drop offs.

Complaints and Incidents
All complaints will be reviewed by the Project Manager within 24 hours. From there, a remedy for the issue would be offered in addition to the City being contacted as to the status of the issue within 48 hours. Appropriate action would be taken to ensure the complaint does not arise again in any area of our operations.

We view incidents between drivers and passengers as among the most serious of problems that can occur in a program like this. CYC is a service business, and therefore any incident that may occur is not acceptable. Once a report of an incident is received, the Field Operations Supervisor will be charged with obtaining the details of the incident and following up. A detailed report of any accident, injury, or any dispute will be completed and provided to the City.

Per our routine day-to-day operations, any and all accidents receive the immediate attention of CYC accident investigators. These individuals are charged with rapidly responding to an accident scene. They use the appropriate reporting protocols to complete a formal investigation report that includes interviews of affected parties, measurements of the scene and photographs of the incident and the surroundings.

CYC was one of the first taxicab companies in the U.S. to electronically archive all trip data and continues to do so as a matter of routine, for three years so as to permit rapid forwarding of this data upon request.

Detailed itemization of trip data is included in the monthly invoicing. An accounting of ridership, in a line -by-line format is provided so as to aid in auditing and oversight of the program.

Experience
CYC has been in the Seniors and Paratransit transportation business since its inception some twenty plus years ago (1995), and is the current service contractor for seniors' programs in the cities of Yorba Linda, Fullerton, Cypress, Laguna Hills, Laguna Woods, La Habra, Orange, Garden Grove, Rancho Santa Margarita and others. Additionally, we are the primary contractor for John Wayne Airport, a franchise in the City of Anaheim and
Has a number of independent private care organizations, all requiring ADA compliance and driver Sensitivity Training programs.

Of particular note are the twelve years' experience servicing the 25,000 seniors residing in Laguna Woods with a consistent sub 1% complaint record.

As the John Wayne Airport (JWA) contractor, we are continually challenged to innovate and update our fleet and methods for accommodating the traveling public. What we learn from our operations at JWA are modern fleet protocols, advanced customer service methods, situational awareness training for our staff and drivers, and skills is 15 handling seniors, developmentally disadvantaged and varying cultural expectations.

These advances are incorporated into our street -fleet driver training programs and help ensure consistency throughout our fleet.

Fleet and Maintenance
CYC has a diverse fleet consisting of conventional sedans, 6 -passenger minivans, and ADA compliant wheelchair -access vans. The average age of the CYC fleet is 4 years.

All of our taxicabs undergo a rigorous maintenance program, designed to ensure safe and dependable transportation for passengers. Records of inspections and maintenance logs are kept by our company as a permanent record for the vehicles.

These records are available for City staff review upon request.

The heart of our vehicle maintenance program called Preventive Safety and Maintenance Inspection (PSMI). This program is designed to identify and correct any and potential vehicle issues before they become a more serious problem.

Monthly Safety Inspections
Every cab in our fleet is inspected approximately every 30 days, to check for any vehicle malfunctions or unsafe conditions including, but not limited to:
• Headlights, tail lights, brake lights, interior lights, and turn signals • Steering
• Windshield wipers
• Tires
• Oil, transmission fluid, etc.
• Warning lights on display
• Body, windshield or interior damage
• Leakage of any fluids
• Horn
• Mirrors
• Double-check the hood to ensure both latches are fastened securely • Wheelchair Vehicles: hand rails, wheelchair tie -downs (manual or power), internal and exterior lighting, operation of ramp/lift, etc.

If any malfunction or damage is observed, the vehicle is not driven.

Interval PMSI Inspections
PMSI inspections are conducted at 6,000 -mile intervals. The vehicle's engine oil and filter are changed at each inspection, and the brakes are inspected and adjusted, if necessary. Every 30,000 miles, each vehicle undergoes a more through PMSI, which includes items not specifically addressed in the preceding inspections.

Automated Maintenance Trackina System
Our company uses an automated driver and vehicle maintenance tracking system which proactively monitors every driver and vehicle in the fleet and records the mileage of

each vehicle weekly. Critical driver and vehicle in the fleet and records the mileage of each vehicle weekly. Critical driver date tracked by our system includes:
• Driver license and expiration
• Norton Medical expiration (drug screening)
• OCTPA driver permits and expiration
• H6 infractions
Critical vehicle data tracked includes:
• Vehicle registration and expiration
• Vehicle mileage (weekly) and preventative maintenance required • OCTAP permits and expiration
The program also contains a history of the vehicles' previous inspections. Based upon all of this information, the program will sort the entire fleet and will identify the vehicles that will be coming due for an inspection within the next week, as well as identifying which inspection is due. This information is then conveyed to the Scheduling and Dispatch Department to ensure that the required vehicles are available for the Maintenance Department on the day that they are requested.

All CYC cabs are professionally washed on a weekly basis and drivers are required to maintain a clean and tidy vehicle at all times. All cabs are randomly inspected in the field. Any dirty or foul smelling vehicles are removed from service right away, and re- inspected for corrections before being returned to service.

California Yellow Cab has been taking the following steps to protect both the seniors and drivers from the spread of the Covid-19 virus. Although it is not guaranteed that

they will not be exposed, studies have shown that if followed there will be a greatly decreased likelihood of contracting the virus.

Every Three Days
• Vehicle is disinfected at the main office
• Complete thorough cleaning of all interior surfaces
• Restock of all required supplies
Start of Each Day
• Driver will check supply inventory of masks, gloves, and disinfecting wipes
• Wipe down of all interior surfaces
• Safely dispose of any used cleaning supplies or protective equipment After Each Passenger
• Using the disinfecting wipes and while wearing gloves they will wipe down passenger area. Specifically, any area of contact; door handles, window controls, credit card processor, headrest, etc. Note: While we encourage the wearing of facial coverings by all passengers and will make them available for drivers to offer those passengers that do not have them it is still a personal choice that each passenger will make for themselves (unless the City requires all passengers to wear one).

Most CYC cabs are distinct and identical in appearance with a black lower 1/3rd panel and a yellow upper body. Identifying decals are in black, white or silver, and the decals

are arranged in the same position on all vehicles with the California Yellow Cab logo on the front.

Insurance Requirements
Since our vehicles can hold a maximum of 6 riders our automobile liability insurance coverage is with a limit of not less than $1,000,000 each accident.

Operations Base in Santa Ana
Owned by us, our base has approximately 2600 sq. feet of office space and more than 5000 sq. feet of logistics and maintenance facilities, we employ six full-time staff members in our administrative offices and contract with a dozen more on-site fleet - maintenance technicians and specialists in our independently owned and operated service facility.

All scheduled and unscheduled maintenance, with the exception of certain bodywork and machine shop work, is performed here. Our maintenance facility is fully equipped to easily perform maintenance ranging from routine oil changes to complete driveline and chassis rebuilds. Our shop meets all local zoning requirements and possesses the equipment and is staffed by highly trained and certified technicians.

Driver Training & Policies
All drivers with California Yellow Cab (CYC) are independent contractors, as is the case with all cab companies in the County.

All applicants must be able to produce the following:
• An Excellent Driving Record
o Current, valid California Driver's License
o Verified ten-year (H6) driving record with no more than two moving violations within the previous three years, and ZERO serious violations such as reckless driving, or driving while under the influence of drugs or alcohol
• OCTAP Taxi Driver Permit
o Pass a drug and alcohol screening initially, annually, and randomly o Be Live Scan fingerprinted with the Orange County Sheriffs Department o Successfully pass a State and Federal background check o Provide proof of legal residency
o Be placed on the DMV Pull -Notice program
o Be photographed with copies placed into their permanent OCTAP record Only after successfully producing the above will a prospective driver be considered for a Lease under the CYC livery.

CYC uses a driver training program comprised of a four -module training platform called Operations, Safety, Service and Review (OSSR). OSSR focuses much more in-depth on customer service, fare collection policies and sensitivity training for providing rides to

seniors and individuals with disabilities. Encompassing some 30 hours of classroom and on -the -road training, and typically presented over a 3 -day training period.

Training occurs before the driver is leased a vehicle, annually and refresher trainings are available every six months. If there is an update or changes to program guidelines trainings are conducted right away to ensure all drivers understand and follow the new guidelines.

All of the seniors programs we service have asked that our drivers wear a white shirt with dark trousers and dark -color shoes. Drivers have the option of participating or not, but if they elect to participate, they must adhere the programs' requirements.

Drug and Alcohol Policy
CYC is dedicated in providing safe, dependable, and efficient transportation services to our customers. Our safety -sensitive employees' and affiliate's use of illegal drugs and misuse of alcohol poses a significant risk to public safety, as well as the employee's and affiliate's health and wellbeing, and can cause loss of efficiency, productivity, or a disruptive work environment. CYC's drug and alcohol policy is intended to comply with all applicable State and Federal regulations governing workplace anti-drug use and alcohol misuse programs in the transportation industry. They include DOT 49 CFR Part 40 as amended, ("Procedures for Transportation Workplace Drug and Alcohol Testing Programs"); FTA 49 CFR Part 655 ("Prevention of Alcohol Misuse and Prohibited Drug Use in Transit Operations"); DOT 49 CFR Part 29 ("Drug -Free Workplace Act of 1988"); and CA Govt. Code Section 8350 et. Seq. ("Drug -Free Workplace Act of 1990"). The policy incorporates the requirements of above regulations for safety -sensitive

employees and others when so noted (this policy is available at any time). Drivers undergo an FTA Drug test initially (pre-employment) and must be enrolled in a random pool.
23 Experience
California Yellow Cab (CYC) is aware of the scope of work and all the tasks that the City of Placentia requires. The following information includes references and current clients:
2004 -Present
City of Laguna Woods
Yolie Trippy, Deputy City Clerk
24264 El Toro Road, Laguna Woods, CA 98263
T949-639-0561 vtriDovCa citvoflagunawoods.com
Senior Mobility Proaram for Laauna Woods' residents. Non-emeraencv Medical Transportation is available for anv non-emeroencv medical trios beainnina or ending in Lacuna Woods (within Oranae County and Lona Beach VA). Seniors may use the services in Laauna Woods for social. personal care. and shopping transportation. 2012 -Present
City of Orange
Katherine Connaghan, Executive Director
170 S Olive St, Orange, CA 92866
T714-538-9633 katherine(a oranceseniorcenter.ora
SMP for residents of Oranae. Transportation is provided for non-emeraencv medical. appointments, pharmacy, grocery store, and senior center trios. 2012 -Present
City of Mission Viejo
Fran Aihara, Recreation & Community Services
24932 Veterans Way, Mission Viejo, CA 92692
T949-470-3062 faihara(a�citvoimissionvieio.ora

SMP for residents of Mission Viejo. Transportation is provided for non -emergency medical appointments. John Wayne Airport, pharmacy, grocery store. and senior center trips.
2012 -Present
City of Laguna Hills
Kayle McDonald, Administrative Assistant
T949-707-2681 kmcdonald(c�laaunaillsca.aov
24035 El Toro Road, Laguna Hills, CA 92653
SMP for residents of Lacuna Hills. Transportation is provided for non -emergency medical appointments, John Wayne Airport, pharmacy, crocery store. and senior center trips.
2017 -Present
City of Lake Forest
Vicky Blethen, Recreational Manager
T949-461-3453 VBIethen(c�Iakeforestca.gov
100 Civic Center Dr, Lake Forest, CA 92630
SMP for residents of Lake Forest. Transportation is provided for non-emeroencv medical appointments. shoppina. social. oersonal care and senior center trips.

TAB #2
26 Equipment/Safety Violations
NONE

1 Ne, 03
2a

•
414 4444
California Yellow Cab
520 West Dyer Road Santa Ana, California 92707
714.427.2555 www.CaliforniaYellowCnh rnrn
(714)444-4444 1949)444-4444
Felipe Zambrano, Community Services Coordinator
City of Placentia
401 E Chapman Ave,
Placentia, CA 92870
Hello Mr. Zambrano,
(6571444-4444
January 1, 2023
Our vehicles are not inspected by the State of California Highway Patrol (CHP). All of Cabco's vehicles are either a sedan or minivan (maximum of 6 passengers) and are inspected by OCTA.

Sincerely,
Tim Conlon
President
520 W Dyer Road; Santa Ana, CA 92707
T714.427.2555 X1 12
conio 1rcavellow,com

TAB #4
30 1
FFP No. CS -22-01
Exhibit G
Reference Form
Senior Mobility Program RFP No. C5-22-01
Proposer is required to provide a minimum of three (3) references where services of a similar size and nature were performed within the past three (3) years. This will enable the City to judge the responsibility, ex-perience, skiTJ, and business standing of the Proposer references.

Agency Name: SIMP- CIT (OP oRAN&E
Address: t7n c nt rtrc rrntvr (I 4,MF. rA 97RFh
Dollar Value of Contract: 3130.000.00
Contact Nauie: KAT:GIUNE Co`i2LtGTL
Phone Number 714-538-9633
Email: Utherinetaoranr.e:eniprcentmon
Contract Dates: PLY 1. 2021 TO IUN£ 30.2026
Requirements of Contract: Tt:?NSFORt.? 1 ON SERVICES FCR5e00R3 OirRom TH:7F RS1DEN: AND THE ORANGE OMR CENTER SHOPPING rT Nears !H9 xrn!C.er earn nsc
Agency Nance: 511P-CTI"i OF LAGUNA :N1GUa
Address: 224E-02 ;LSO CR 1: RD, LAGUNA?NIGUEL. Ca 92577 Dollar Value of Contract: 599,75aoo
Contact Name: M.ARTRtn7
Phone Number: 949425-5153
Email: rtrt¢*--.4ntcooa=ananteuetorr
Contract Dates: TULY 1, 2022 TO RINE 30.2017
Requirements of Contract: TRr'NSPDRT..TIO!ISERVIeSFORSEN1ORSTOJFR0MTHH IRRESIDE10EAIIDSEACDUHTn'2' S£NIO R & COMMMLrNITYCEHTFR. SE ECTD GRO Y ST0RE5 . AND MEDICAL F.447I11t II•=.

Agency Name: SMP- QTY OF GARDEN GROVE
Addre 11300STANFORD AVE G..RDENGROVECA92840
Dollar Value of Contract 5-205k""
Contact Name: BR—CiD,t&tUTISTA
Phone Number: 714-741-5423
Eatail br ciabT , tv.arg
Contract Dates: TUNE 11,'019roIU1130._034
RequirementsorContract: SincE2014-TF;NSPORT'.TTO'.NSERV:C :FOR SENIORS TO(FROM TIIDRRESIDENC.AND H. LOUIS L ;E:SENIORCENTERS!HO??UNGCarr°...+_!DSEDiC:.iF.AC1ILTS. 21 TAB #5

Exhibit El
Proposal Forst
Senior Mobility FTP No. CS -22-01
Name of A ,encv:.0 ARCO YELLOW INC., PI3;k CALIFORNIAYELLOW (:111; Type of Agency: __'1 BANS?ORTATION SERVICES
Agency Address: 520 W DYER ROAD. SANTA ANA CA 927i)7
Agency phone: 714427-255S
RFP No. CS -22-01
Ernait; TCONLON@CAYELLO'N.COM
item Dcscriptiom
N urnhcr:

Single, 53.511 per mite (.?i 3..50/nil) rare :or a maxmu]Tt C:.pa,city of 5 (tine) Passenger
7 Minimum rate of 520,00 per trip, per participant
tinit. Cost: Extended
Cost:

1. In submitting this Proposal, Respondent agrees to comply with the terms and conditions illustrated in this RF'F'. Proposals shall include all costs, fees, licenses, equipment, drivers, services, insurance, fuel, to[ls, etc. and shat: have n:; hidden costs. Cite will not incur any additional costs above the Contractor's Proposal price.
'Total Proposal. Arca iniit: fj
.y a✓ - �vt , tr1 &eV/hi q'//a(r Dollars: Saa0. 00
,;Irr„e
r.... "
0/2023
Signam (e: _ sc ;Pj� 1 2tt::

Printed Name and Title:

TIM CONLON. PRESIDENT

ACC) RO
AGAVHOL-01

CERTIFICATE OF LIABILITY INSURANCE
NICK

DATE (MM/DD/YYYY)
5/15/2025
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

PRODUCER License # 0C36861 CONTACT Nicole Ick
NAME:

San Diego-Alliant Insurance Services, Inc. PHONE FAX
701 B St 6th FI (A/C, No, Ext): (619) 541-4832 (A/C, No):

San Diego, CA 92101SS:

E-MAIL [email protected]
ADDRE

INSURED
OCY Management, LLC
520 W Dyer Road
Santa Ana, CA 92707

COVERAGES

INSURER(S) AFFORDING COVERAGE
INSURER A: Golden Bear Insurance Company
INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

CERTIFICATE NUMBER: REVISION NUMBER:

NAIC #
39861

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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS

LTR INSD WVD IMM/DD/YYYYI IMM/DD/YYYYI

A X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR X GBL13000374-03 5/1/2025 5/1/2026 GEN'L AGGREGATE LIMIT APPLIES PER:

X POLICY JE
PRO 1 LOC
OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED SCHEDULED

AUTOS ONLY AUTOS

HIRED NON -OWNED

AUTOS ONLY AUTOS ONLY

UMBRELLA LIAB

EXCESS LIAB
DED RETENT ON $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
OCCUR

CLAIMS -MADE
YIN
N/A

EACH OCCURRENCE S

DAMAGE TO RENTED
PREMISES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL 8 ADV INJURY S
GENERAL AGGREGATE 0
PRODUCTS - COMP/OP AGG $

ASSAULT BATTERY

COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY (Per person) S
BODILY INJURY /Per accident) S

PROPERTY DAMAGE
(Per accident) $

EACH OCCURRENCE S
AGGREGATE $
$
PER
OT
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE S
E.L. DISEASE - POLICY LIMIT S
1,000,000
100,000
2,500
1,000,000
2,000,000
Included)
500,0001
DESCRIPTION OF OPERATIONS I LOCATIONS !VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate is subject to policy limits, conditions and exclusions. 30 Day Notice of Cancellation - 10 Days for Non -Payment Additional Insureds: "The City of Placentia and its elected and appointed boards, officers, officials, agents, employees, and volunteers are additional insureds with respect to: liability arising out of activities performed by or on behalf of the Consultant pursuant to its contract with the City; products and completed operations of the Consultant; premises owned, occupied or used by the Consultant; automobiles owned, leased, hired, or borrowed by the Consultant."

CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E Chapman Avenue
Placentia, CA 92870
ACORD 25 (2016/03)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE
© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

POLICY NUMBER: GBL 13000374-03 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s) All entities as required by written contract
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Section II — Who Is An Insured is amended to include
as an additional insured the person(s) or organiza-
tion(s) shown in the Schedule, but only with respect to liability for "bodily injury', "property damage" or "per- sonal and advertising injury' caused, in whole or in part, by your acts or omissions or the acts or omissions of
those acting on your behalf:

A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or rent-
ed to you.

Other Insurance -subject to all terms and provisions of the policy, insurance as provided by this endorsement shall be deemed primary and noncontributory, but only with respect to work performed by or on behalf of the named insured in connection with the described project
CG 20 26 07 04
© ISO Properties, Inc., 2004 Page 1 of 1 0

J4WRL
CABCYEL-01

CERTIFICATE OF LIABILITY INSURANCE
N
NICK

DATE (MM/DD/YYYY)
5/28/2025
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

PRODUCER License # 0C36861 CONTACT Nicole Ick
NAME:

San Diego-Alliant Insurance Services, Inc. I
PHONE
No, Ext), (619) 541-4832 I FAX
701 B St 6th FI (A/C, No):

San Diego, CA 92101E-MDREAIL SS: [email protected] AD

INSURED
OCY Management, LLC
520 W Dyer Road
Santa Ana, CA 92707

INSURER(S) AFFORDING COVERAGE
INSURER A : Paratransit Insurance Company a Mutual Risk Retention Group INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

NAIC #
44130
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED —O THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRA ;T OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS.

INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WV❑ IMM/DDIYYYYI IMMIDDNYYYI

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S

DAMAGE TO RENTED
PREMISES (Ea occurrence) S

CLAIMS -MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY PRO- LOC
JECT
OTHER:

A AU'OMOBILE LIABILITY
ANY AUTO PG124224 10/1/2024 10/1/2025
_

OWNED SCHEDULED

AUTOS ONLY AUTOS

AUTOS ONLY AUUTOS ONEY

UMBRELLA LIAB

EXCESS LIAB
OCCUR

CLAIMS -MADE
DED RETENTION $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y/N
N/A
MED EXP (Any one person) S
PERSONAL & ADV INJURY $

GENERAL AGGREGATE S
PRODUCTS - COMP/OP AGG $

COMBINED SINGLE LIMIT
(Ea accident) S
BODILY INJURY (Per person) $
BODILY INJURY 'Per accident) $

PROPERTY DAMAGE
(Per accident) S
EACH OCCURRENCE $

AGGREGATE S

PER OTH-

STATUTE ER
E.L. EACH ACCIDENT S
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 10 Day notice of cancellation in the event of non-payment of premium.

CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E Chapman Avenue
Placentia, CA 92870
100,000
300,000
100,000

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE
all 7 ✓ L4-01.

The ACORD name and logo are registered marks of ACORD

AC� ®
�� CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDD/YYYY) 06/01/2025
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

PRODUCER I CONTACT Lorelei C. Noonan
NAME:

Faith Branvold c/o Sunset Business Insurance Solutions I HONNc. Extl: 818-827-0315 I (AIC. Nol: 310-301-3280 uuc7590 N Glenoaks Boulevard, Suite 200 1 E-MAIL
ADDRESS: [email protected]
Burbank, CA 91504 1 INSURER(S) AFFORDING COVERAGE MAIC # INSURER A: StarStone National Insurance Company 25496
INSURER B:

I INSURER C :

INSURER D :
1 INSURER E :
1 INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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 'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
LTR wsn wvn POLICY NUMBER IMMIDD(YYYY1 IMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $

CLAIMS -MADE OCCUR DAMAGE TO RENTED
PREMISES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $

INSURED
OCY Management, LLC
520 West Dyer Road
Santa Ana, CA 92707
GEN'L AGGREGATE LIMIT APPLIES PER:

IPOLICY JEcT P61LOC
OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED SCHEDULED
HONLY ❑ AUTOS

HIREDIREO NON -OWNED

AUTOS ONLY AUTOS ONLY

UMBRELLA LIAB

EXCESS LIAB

DED I I RETENTION S

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANYP ROP RI ETO R/PARTN ER/EXECUTIV E
A OFFICER/MEMBEREXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
OCCUR

CLAIMS -MADE
YIN
Y
NIA Y T10250737
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
(Per accident)
$
EACH OCCURRENCE $
AGGREGATE $
$
X I STATUTE 1 I ERH
06/01/2025 06/01/2026 E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
1,000,000
1,000,000
1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of subrogation in favor of The City of Placentia and its elected or appointed boards, officers, officials, agents, employees, and volunteers.

CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E Chapman Avenue
Placentia, CA 92870
ACORD 25 (2016/03)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

The ACORD name and logo are registered marks of ACORD

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA WC 04 03 06
(Ed. 04-84)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from US.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.

The additional premium for this endorsement shall be 5% of the California workers' compensation premium otherwise due on such remuneration.

Schedule
Person or Organization
City of Placentia
401 E Chapman Ave
Placentia, CA 92870
Job Description
Waiver of Subrogation in favor of the City of Placentia, its elected or appointed
officials, officers, employees and volunteers.

The additional charge shall be no less than $500 policy minimum premium.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective
Insured
Insurance Company
WC 04 03 06
(Ed. 04-84)
06/01/25 Policy No.

OCY Management, LLC
StarStone National Insurance Company
T10250737 Endorsement No. 54
Policy Effective Date 06/01/25
Countersigned By
©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.

Placentia City CouncilMay 19, 2026

Placentia City Council
May 19, 2026