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Insurance Certificates 2020/21 Johnson, KarenINSURANCE REVIEW RE: Please list the Contracting Party / Vendor Name, type of agreement to be executed, including any change orders or amendments, and the type of services to be provided. Make sure to list any related Project No. and Project Name. Insurance certificates required per the Agreement: ACCORD Certificate dated 10-days prior or less _____________________________ enter ACCORD issue date Commercial General Liability Insurance: $1,000,000 per occurrence/$2,000,000 aggregate OR $2,000,000 per occurrence/$4,000,000 aggregate Additional Insured Endorsement naming City of La Quinta Primary and Non-Contributory Endorsement Automobile Liability: $1,000,000 combined single limit for bodily injury and property damage. Workers’ Compensation: Statutory Limits / Employer’s Liability $1,000,000 per accident or disease Workers’ Compensation Endorsement with Waiver of Subrogation Sole Proprietor Professional Liability (Errors and Omissions): Errors and Omissions Liability insurance with a limit of not less than $1,000,000 per claim Cyber Liability/Technology Errors and Omissions Liability Insurance: $1,000,000 per occurrence/loss Other: ________________________________________________________ List other insurance types such as – molestation, harassment, etc. Approved by: ________________________ Date: ________________________ Karen Johnson, Instructor Agreement (FY 20-21) for Stretch and Restore and Sculplt, Fit and Core Class instruction to be performed at the Wellness Center. 8/26/2020 ✔ ✔ ✔ ✔ Monika Radeva 8/31/2020 !"#"! $$" #"%$& ' (")!)"!*!*+,!*-. /""01 /""+!2+ , 3 3 ' ' 44 1567" 8"! #!+!)"!*$#8"!+ 156/7 1567 1567 9"!:$!$! ; ! "(" $ <"=)!",; 15667 6>566 ?, , @ ((6<A66<</<B (A666 6(161 6"$**)!*? , <(1(6 @ 5(66@ !+$!8$!?, @ -611<</<B 61<CD:5B ?, , A66<AA6A6 ?3, , A6E<AA6A6<(<6167 51F(AA ?3, , @ @ <B :6< >9 4 B5 (/61A<6<( 6"** ! <<.651 1>65<651 /<B:5B 8$! >651 .651 /<B:5B "** ! 6B(A6 "** ! 5<BF66 B56>6> 5<B7 AA 6>566 5<(1(6 AA6A6 65/<6 66 ! .15 B<(1 > 6 B 666@65D6 --6(6(/66@<56G 6<6>6 "#$"%&'()# 6<1616F6(<B66 &+, *H)! 16<D11H$2 6<1616F<B<( )! $$ "! " "&$$2!!+" ""!" $!"!) H)$!+28* $$8"$!$&!"# !) I*8""H+)!&$#" $!"!) E$ !!* ! <"=)!".!! 43 ! "<"-$! ",,; <"=)!",,; * &)&)"$ "!<056+8$)* #(H! $ "#!$! )&)" $!$)$!&$)&)"$ !($&()! $#! &05.A0- D6+(HJ)$#"! )$! $!$&8$)*+)"!8$)#"*K( "!! $#!"#!$!)&)" $!$)$!&$)&)"$ !($& ()! $#! &)" $& !("!) $ !$ )$!(")$!")H1!(! !( + "($/ 8!" $ 8$ ()+ "! )&)" $ + !$ $ "&&#"* $ !"* "#! + I! $")$""&&$ H*8$) $! POLICY NUMBER: PHPK1922710-001 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION CG 20 26 07 04 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE General Liability(Ed. 7-04) Name Of Additional Insured Person(s) Or Organization(s): 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. PI-GL-005 (07/12) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization (Additional Insured): Effective Date: 01/01/2020 SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured. The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in SECTION III – LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to "rzeN 0-(5 " as follows: I am the authorized representative of � /mil TYUU 5S - ��L�"1�1 jO�—/hJ , CP,-0 an independent contractor for the purposes of the California Workers' Compensation and Labor laws. This organization will hire no employees other than the parents, spouses, or children of its board members for work required for any bid or contract awarded to y2 00 -)NSuN } . All worked required will be performed personally and solely by me, other board members of the organization, their parents, spouses or children, or persons who perform voluntary service without pay to the organization. If, however, the organization shall ever hire employees to perform this contract or any portion thereof, the organization shall obtain Workers' Compensation Insurance and provide proof of Workers' Compensation Insurance coverage to the City of La Quinta. If the organization shall ever hire a subcontractor to perform this contract or any portion thereof, and the subcontractor has employees, then the organization shall require its subcontractor to obtain Workers' Compensation Insurance Coverage, or the organization shall obtain Workers' Compensation Coverage for that subcontractor's employees. This document constitutes a declaration by the organization against its financial interest, relative to any claims it should assert under the California Workers' Compensation and/or Labor laws against City of La Quinta relatipg to any bid or contract awarded to The organization will defend, indemnify and hold harmless the City of La Quinta from any and all claims and liability, including Workers' Compensation claims and liability that may be asserted or established by any parry in the event the organization hires an employee in violation of this addendum, and the organization will further indemnify the City of La Quinta for all damages the City of La Quinta thereby suffers. I agree that these declarations shall constitute an addendum to any bid or contracts awarded to Date Y,."— Auth z presentative