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Cox Martial Arts Academy CIQ 9.14.23Special Instructor Agreement Contract Submission Checklist Steps to be completed by Recreation Coordinator/Specialist: Y N/A Contract Proposal (completed annually and in full) Strategic Program Plan (New Programs, approved by Supervisor & PAM) Or Program Determinant Evaluation Form (Returning Programs, approved by Supervisor & PAM) Conflict of Interest Questionnaire (send to Cheyenne.DeFee@cityofdenton.com, CC Mary.McFall@cityofdenton.com) Individual Contractor Analysis with email approval (Human Resources Compliance Specialist x7810) Liability Insurance Determination (Complete intake form and attach program proposal, Risk will make the official determination.) COD General Release (Activity is low-risk and does not require liability coverage) Liability Insurance required (Activity does not require workers comp or automobile coverage) Liability, Automobile, and Workers Comp Coverage Required Liability Insurance Certificate Review if required from step above. (Smartsheet Intake Form) • Policy must cover a minimum of $1,000,000 per occurrence. • City of Denton must be listed as certificate holder & additional insured. • Address must be listed as: City of Denton, 321 E. McKinney St. Denton, TX 76201 Signed Contract (only the vendor/user signs this, it will receive all other signatures via Docusign) Special Instructor Agreement w/ Exhibits A, B, C as listed in the agreement. CivicRec Contract; Acknowledged on___________________ Vendor Request-Substitute W-9 (new contracts or updated info, Robin to complete the Smartsheet intake) Send link for Background Check- Agreement, Disclosure and Authorization after all items have been received. (Attach background check clearance email.) P.O. Request Form (Excel, only needed if we will be collecting registration fees and paying contractor) Upload all documents, including this checklist, as a PDF to the corresponding row in the LS Contract Submission Smartsheet. • Documents should be uploaded as separate files and clearly labeled. • PO Request should be uploaded as an Excel file, not a PDF. Complete the form through “Ready for Review” all approvals will be complete through an automated workflow. Steps to be completed by Recreation Supervisor then PAM via Smartsheet Workflow: Strategic Program Plan review & approval Contract Packet review & Approval PAM will combine all required documents into one PDF upon final approval. PO stays in Excel format. Steps to be completed by Leisure Services Admin: Upload Agreement with all exhibits and contract packet to DocuSign Signature path: Manager Initials, Department Director, City Manager, City Secretary Enter OR number and approved PO number when received 4 4 4 4 4 4 4 4 4 4 4 4 4 12/07/2023 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 1 Thomas, Megan L. From:Skawinski, Deby Sent:Thursday, September 14, 2023 4:11 PM To:Muller, Yosselin Cc:Skawinski, Deby Subject:RE: Individual Contractor Analysis - Tyrone Cox Attachments:ICA - TC.pdf Hi Yosselin, Thanks for sending this over. Mr. Cox is providing services as Cox Martial Arts Academy LLC and is not an Independent Contractor. Please proceed using your normal purchasing processes for a vendor. Thanks and have a great rest of your week!   Best~    Deby   From: Muller, Yosselin <Yosselin.Muller@cityofdenton.com>   Sent: Thursday, September 14, 2023 3:09 PM  To: Skawinski, Deby <Deby.Skawinski@cityofdenton.com>  Subject: Individual Contractor Analysis ‐ Tyrone Cox    Good Afternoon Ms. Deby,    May you please review the attachment?    Thank you,    Yosselin S.Muller Martin Luther King, Jr. Recreation Coordinator City of Denton - Parks and Recreation Yosselin.Muller@cityofdenton.com (940) 349-8147 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 12.2018 Individual Contractor Analysis The questions below are designed to determine whether an individual can be engaged as an independent contractor (IC) without violating Department of Labor or IRS guidelines. If you intentionally engage someone as an independent contractor when they do not meet the guidelines, you could be subjecting the City to penalties and fines. Willful violations will be grounds for disciplinary action. If you have any questions about the information below, please contact the Human Resources Compliance Specialist at ext. 7810. Date: Name of Individual being considered for IC services: Name Individual Does Business Under (e.g., company name, personal name, etc.) What type of entity does the Individual have? (e.g., LLC, Sole Proprietor, Corporation, etc.) Name of Person Completing Form: Department/Division: Extension: 1. Does the individual currently work for the City of Denton? Yes ܆ No ܆ 2. Has the individual ever worked for the City of Denton in any capacity? (Including retirees, interns, volunteers, temporaries, seasonals, etc.) Yes ܆ No ܆ 3. Has the individual previously done work for the City of Denton as a contractor? Yes ܆ No ܆ 4. Will this individual be restricted from offering the same or similar services to the public while performing services for the City of Denton? Yes ܆ No ܆ 5. Will the department set the hours the individual will be required to work? Yes ܆ No ܆ 6. Will the department provide the supplies, materials, equipment, and/or space, to perform the services requested? Yes ܆ No ܆ 7. Will the department provide specific training and/or instruction to the individual? Yes ܆ No ܆ 8. Will the individual perform the services on City of Denton premises? Yes ܆ No ܆ 9. Is the control* of the services directed by the department? Yes ܆ No ܆ 10. Is the individual permitted to hire others to assist with the services? Yes ܆ No ܆ 11. Will the individual perform on-going services without a defined end date? Yes ܆ No ܆ 12. Will the department reimburse the individual for expenses incurred for the services? Yes ܆ No ܆ 13. Will the individual invoice the City on an hourly basis for the services provided? Yes ܆ No ܆ 14. Will the department be responsible for any cost overruns for the individual’s services? Yes ܆ No ܆ *Examples of control include instructing the individual as to when and where to do the work; what tools or equipment to use; where to purchase supplies and services; what work must be performed by a specific individual; or what order or sequence to follow when performing the work. If you answered “yes” to any of the questions above, please call the Human Resources Compliance Specialist at ext. 7810 to discuss. If you answered “no” to all of the questions above, you may work with Purchasing to engage the individual as an independent contractor. You will need to submit this form to Purchasing to initiate the process. September 14, 2023 Tyrone Cox Cox Martial Arts Academy LLC Yosselin Muller Parks and Recreation / LS / MLK 8147 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 Coverage is only extended to U.S. events and activities. ** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/22/2023 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 CONTACT NAME: Mass Merchandising PHONE (A/C, No, Ext): 1-800-648-6406 FAX (A/C, No): 1-260-459-5940 E-MAIL ADDRESS: info@martialartsinsurance-kk.com PRODUCER CUSTOMER ID: K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 INSURER(S) AFFORDING COVERAGE NAIC # INSURED 2001492388 CP# 195 INSURER A: Markel Insurance Company 38970 INSURER B: INSURER C: INSURER D: INSURER E: Tyrone D. Cox DBA: Cox Martial Arts Academy PO Box 270413 Flower Mound, TX 75027 A Member of the Sports, Leisure & Entertainment RPG INSURER F: COVERAGES CERTIFICATE NUMBER: 2000593901 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea Occurrence) $1,000,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GEN’L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY PROJECT LOC PRODUCTS – COMP/OP AGG $1,000,000 A OTHER: X M1RPG0000000131400 09/14/23 12:01 AM 09/14/24 12:01 AM PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY (Per accident) HIRED AUTOS ONLY NON-OWNED AUTOS ONLY PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION PER STATUTE OTHER Y / N E.L. EACH ACCIDENT E.L. DISEASE – EA EMPLOYEE WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY ANY PROPRIETOR/PARTNER/ EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A E.L. DISEASE – POLICY LIMIT PRIMARY MEDICAL MEDICAL PAYMENTS FOR PARTICIPANTS EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Martial Arts Instructor The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION 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 City of Denton 901 B. Texas Street Denton, TX 76209 Owner/Manager/Lessor of Premises © 1988-2015 ACORD CORPORATION. All rights reserved. DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER: M1RPG0000000131400 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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) City of Denton 901 B. Texas Street Denton, TX 76209 Named Insured: Tyrone D. Cox DBA: Cox Martial Arts Academy CP# 195 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 1 Riddle, Jane D. From:Harris, Tiffany Sent:Wednesday, November 8, 2023 3:00 PM To:Riddle, Jane D. Subject:Re: Instructor insurance questions Yes, ma’am. That is all he needs.    Thank you,  Tiffany Harris      From: Riddle, Jane D. <Jane.Riddle@cityofdenton.com>  Sent: Wednesday, November 8, 2023 2:50:58 PM  To: Harris, Tiffany <Tiffany.Harris@cityofdenton.com>  Subject: RE: Instructor insurance questions      THANK YOU!!  So, I will reach out to get an update of the same but that’s all he needs?  Wonderful!     From: Harris, Tiffany <Tiffany.Harris@cityofdenton.com>   Sent: Wednesday, November 8, 2023 2:42 PM  To: Riddle, Jane D. <Jane.Riddle@cityofdenton.com>  Subject: Re: Instructor insurance questions     Hi Jane,  The COI provided is expired as of September this year. We will need a current COI that has the same coverage.     Thank you,  Tiffany Harris        From: Riddle, Jane D. <Jane.Riddle@cityofdenton.com>  Sent: Wednesday, November 8, 2023 2:39:58 PM  To: Harris, Tiffany <Tiffany.Harris@cityofdenton.com>  Subject: Instructor insurance questions      Tiffany –  I have moved from the Senior Center to MLK Jr Recreation Center!! I have been here about 3 weeks and loving it.  BUT… (you knew that was coming, right?) I am working with an instructor for a Karate/Self Defense class. I have a copy  of his certificate of liability insurance.   Do you need something else from me in order to make the determination that I can continue this process for getting him  started in March?     Thank you!  Jane  DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B21/24/2024 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2Director of Parks and RecreationParks and RecreationGary Packan DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 1 Thomas, Megan L. From:Brown, Cheylon Sent:Thursday, October 5, 2023 1:44 PM To:Muller, Yosselin Subject:FW: Contractor Approved     From: Caitlin Essex via Smartsheet <automation@app.smartsheet.com>   Sent: Thursday, October 5, 2023 1:23 PM  To: Brown, Cheylon <Cheylon.Brown@cityofdenton.com>  Subject: Contractor Approved     This message has originated from an External Source. Please be cautious regarding links and attachments.    To help protect your privacy, Microsoft Office prevented automatic download of this picture from the Internet.     Hello, the following individual has been approved and ready for assignment.  To help protect your privacy, Micro so ft Office prevented automatic download of this picture from the In ternet.   Background Check Submission Log Sheet ‐ PARD Changes since 10/5/23 11:23 AM    1 row changed    1 row added or updated (shown in yellow)    Row 5 First Name Tyrone Last Name Cox Classification Adult Contractor Status Approved Approved Date 10/05/23 Clearance Expires     Changes made by caitlin.essex@cityofdenton.com DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2 2 You are receiving this email because you are subscribed to a workflow "Contractor Approved - Alert" (ID# 4859472800704388) on sheet Background Check Submission Log Sheet - PARD Exclude your changes from all notifications | Unsubscribe Powered by Smartsheet Inc. | Privacy Policy | Report Abuse/Spam ‐—‐‐‐–—‐–‐‐‐–––‒——‐–      DocuSign Envelope ID: 5D26E7D6-33FF-4802-99FB-7A3425C6E8B2