2018/19 Pollution Coverage��y4lliant
SECTION I — GENERAL INFORMATION
1. APPLICANT NAME: Citv of La Quinta
Street Address: 78-495 Calle Tampico
City/State/Zip Code: La Quinta, CA 92253
Contact Name: Pam Nieto Contact Title
Telephone: 760-777-7103 Fax:
E-mail: nietot@-laquintaca.gov Website:
Federal Employer Identification Number: 95-3740431
Risk Management Specialist
760-777-7146
www.laquintaca.gov
2. POPULATION: 42,098 (As of 6/30/19)
3. PAYROLL: $6,801,702 (State Compensation Report Calendar Year 201
4. ANNUAL REVENUES: $63,272,960 (Revenue as of 2019/19)
5. PROPERTIES:
Attach a complete list of all locations to be considered for coverage which includes the physical
address and current occupancy/use for each specific location.
SECTION II — IN -FORCE POLLUTION COVERAGE
1. CURRENT POLLUTION COVERAGE PROVIDED UNDER OTHER POLICIES:
Are you a new applicant to the CA JPIA Pollution Program? ❑ Yes X No
If yes, please summarize the current in -force pollution coverage in the table provided below.
Current Carrier
Policy Period
Limits or
Sub-limits
Self-insured
Retention Amount
Premium
$
$
$
a Has any insurance company denied, canceled or non -renewed pollution liability
coverage?
If yes, give details:
b. Have any claims been filed and/or losses been incurred against any pollution
policy?
If yes, give details and attach loss runs:
SECTION III — RECORD, COMPLIANCE HISTORY AND FUTURE SITE PLANS
1. RECORD:
a. Have you ever been investigated, cited and/or prosecuted for contravention or
violation of any standard or law relating to any release of pollutants?
If yes, give details:
❑ Yes X No
F1 Yes XNo
❑ Yes X No
California JPIA Application (11/2016) Page 1
b. Have you ever had any pollution claims including, but not limited to, claims by ❑ Yes X No
private persons, entities, government agencies, Non -Owned Disposal Sites
(NODS), or other third -parties?
If yes, please describe:
Are you aware of any past or present contamination on, at, under or migrating ❑ Yes X No
from any location herein, or any circumstances which may reasonably be
expected to give rise to a claim or generate a request for coverage under this
policy?
If yes, please identify each site and explain:
COMPLIANCE HISTORY:
a. Have you received any notices of violations (NOVs), fines, penalties, complaints, ❑ Yes X No
or other enforcement actions regarding compliance with environmental law within
the past five (5) years?
If yes, please explain:
b. Are there any statutes, standards, or other city, state and/or federal regulations ❑ Yes X No
relating to the protection of the environment with :which you cannot at present
comply?
If yes, please explain:
Has there been any past, present or planned remediation, monitoring or ❑ Yes X No
sampling to investigate potential contamination on, at, under or migrating from
any location listed herein?
If yes, please provide a written explanation and attach copies of all applicable reports:
E11T1 IRE SITE OI T
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a. Does the Applicant have any plans to sell or sublease any part of the location ❑ Yes X No
and/or sell any of the business operations performed at any location listed
herein?
If yes, please explain:
Does the Applicant have any plans or are they aware of any plans by a future ❑ Yes X No
perspective owner or tenant for development, improvement, betterment,
demolition or plans for changes in use or business operations at any location
listed herein?
If yes, please explain:
C. Does the Applicant have any plans or are they aware of any plans by a future ❑ Yes X No
perspective buyer or tenant to initiate or complete any studies, investigations,
testing and/or monitoring for environmental conditions at any location listed
herein?
If yes, please explain:
California JPIA Application (11/2016) Page 2
SECTION IV — EXPOSURE AND RISK MANAGEMENT INFORMATION
1. RISK CLASSES:
a. Do you own or operate any Aboveground Storage Tanks (ASTs) and/or ❑ Yes X No
Underground Storage Tanks (USTs)?
If yes, please complete the Underground Storage Tank Coverage Supplemental Application for
each (see attached).
b. Do you own or operate any Water Treatment Facilities? ❑ Yes X No
If yes, please complete the Water Treatment Plant Supplemental Application for each (see
attached).
C. Do you own or operate any Wastewater Treatment Facilities? ❑ Yes X No
If yes, please complete the Wastewater Treatment Plant Supplemental Application for each (see
attached).
d. Do you own or operate any Current of Former Landfills, Transfer Stations, ❑ Yes X No
and/or Recycling Facilities?
If yes, please complete the Recycling/Waste Facility Supplemental Application for each (see
attached).
e. Do you own or operate any Airports? ❑ Yes X No
If yes, please complete the Airport Supplemental Application for each (see attached).
f. Do you perform any pesticide/herbicide applications, maintenance activities, ❑ Yes X No
and/or water/sewer line installations on property you do not own or lease?
If yes, please complete the Contracting Services Supplemental Application (see attached).
2. RISK MANAGEMENT PROCEDURES:
Please attach any written procedures and/or protocols you employ that document your risk management
practices
a. Do you perform standard due diligence investigations on properties prior to X Yes ❑ No
acquisition?
If yes, please explain:
b. Do you perform due diligence and review facility compliance packages on Non- X Yes ❑ No
Owned Disposal Sites (NODS) to which your waste material is sent?
c. Do you have Asbestos and Lead Based Paint Management protocols in place? X Yes ❑ No
d. Do you have Water Intrusion/Mold Management protocols in place? X Yes ❑ No
e Do you require all your Subcontractors to meet minimum insurance requirements X Yes ❑ No
that include Contractor's Pollution Liability (CPL) coverage?
California JPIA Application (11/2016) Page 3
3. SITE SECURITY:
a. Do you currently have an approved Terrorism Prevention and Response Plan? ❑ Yes X No
b. Do you have a cyber security program in place for your operations/facilities? ❑ Yes X No
c. Has a vulnerability assessment been performed on your operations/facilities? X Yes [:]No
SECTION V - SITE OPERATION AND HISTORY
1- Do you have any environmental site assessments or questionnaires that have been ❑ Yes X No
performed for the location(s) where you would like coverage?
If yes, please attach.
2. In what year were the structures on the location(s) built? SOV will be attached for underwriting
3. Please describe the operations that take place at the location(s) for which you are seeking coverage:
SOV will be attached for underwriting
4. Are there any anticipated changes in use of the location(s) during the policy period? ❑ Yes X No
If yes, please describe:
5. What are the previous uses of the location?
6. Has waste ever been disposed of at this location? ❑ Yes X No
If yes, please describe:
7. Is there a dry cleaner at the location? ❑ Yes X No
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If yes, have they been closed in accordance with regulation?
9. With respect to prior coverage, has any Underwriter refused, canceled, or non -renewed ❑ Yes X No
coverage?
(Not applicable in Missouri)
If yes, provide details:
California JPIA Application (11/2016) Page 4
SECTION VI - RAW MATERIALS N/A
Please provide the following information:
QUANTITY j
NAME (at any one time) I STORAGE (on pallet, 55 gallon drum,etc.):
SECTION VII —WASTE N/A
Please provide the following information:
QUANTITY
TYPE OF WASTE (at anv one time) I METHOD OF STORAGE ON-SITE DISPOSAL METHOD
SECTION VIII — WATER
1. Is there any surface water on your location? X Yes []No
If yes, what kind (lined pond, intermittent stream, river, etc.)?
CONCRETE POND ON CIVIC CENTER PARK
2. Are there any potable water wells on your location? ❑ Yes X No
If yes, what kind (lined pond, intermittent stream, river, etc.)? ❑ Yes ❑ No
Do the results meet federal, state, and local standards? ❑ Yes ❑ No
3. Are there third party drinking water wells located within a'/z mile of your location? ❑ Yes X No
4. Is there a septic system at your location? ❑ Yes X No
If yes, is it connected to areas storing hazardous substances? ❑ Yes ❑ No
SECTION IX — THIRD PARTIES
1. Do third parties regularly come on to your location? X Yes ❑ No
If yes, is it connected to areas storing hazardous substances?
NO
How many on an average day? 50 RESIDENTS How often? daily
California JPIA Application (11/2016) Page 5
X N/A
1. What materials are being transported to and from your location?
2. Please describe the conveyance and containment (i.e. 55 gallon drum in pickup truck).
3. How often is your material being picked up and who is the carrier?
4. Please provide the following information on the vehicles you operate by vehicle type:
Cargo or Material Hauled (indicate if Radius of
Vehicle Type Number of Units hazardous) Operation
Private Passenger
Light Truck
Medium Truck
Heavy/Extra Heavy Truck
Trailers
Other:
I
SECTION XI — MOLD X N/A
1. Please provide a copy of your mold management plan and HVAC maintenance plan.
2. Please describe how you respond to water intrusion events (flooding, pipe leakage, etc.):
3. Please provide details If all previous mold -related incidents, claims or losses (attach additional pages if
needed):
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Have you implemented the CDC federal guidelines to protect visitor health? ❑ Yes ❑ No
If yes, please provide a description of measures implemented:
2. Number of visitors per year:
SECTION XIII — PATHOGENIC AND RADIOLOGICAL WASTE %N/A
1. Do you generate or handle radioactive waste? ❑ Yes ❑ No
If yes, please provide a detailed description the source of your waste handling,
storage and disposal methods:
2. Do you generate or handle pathogenic waste? ❑ Yes ❑ No
If yes, please provide a detailed description of the source, your waste handling,
storage and disposal methods:
California JPIA Application (11/2016) Page 6
APPLICANT FRAUD WARNINGS
Any person who knowingly and willfully presents false information in an application for insurance may be
guilty of insurance fraud and subject to fines and confinement in prison.
The proposed insured affirms that the foregoing information is true and agrees that these applications shall
constitute a part of any policy issued whether attached or not and that any willful concealment or
misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy.
After reasonable inquiry, I warrant that the information and statements contained in this application for
insurance are true and correct, and that no material facts have been withheld or misstated. I understand
that this application, and all other materials and information submitted to the Company in connection with
this application for insurance, are incorporated and made a part hereof. I also understand that the Company
will rely upon the application, materials and information submitted in the underwriting process in the
formation of any subsequent contract of insurance entered into.
I understand that the completion of this application does not bind coverage. Acceptance of a quotation
from the Company is required prior to binding coverage with the Company.
Applicant's Signature: Titie:
Print Applicant's Name:
Agent/Broker Name
Pam Nieto
Date: 11/22/19
Chris Tobin — Alliant Insurance Services
California JPIA Application (11/2016) Page 7
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California JPIA Application Pollution Application
Water Treatment Plant WTP Supplemental Application N/A X
Please read carefully and complete this supplemental application for each applicable
facility.
APPLICANT NAME:
1
WTP Name:
Street Address:
City/State/Zip Code:
USEPA / State Identification Number:
2. WTP Specifications:
What year was the WTP designed & built?
• Total Population serviced?
Design Capacity (gallons per day)?
• Average Gallons treated per day?
• Source of water supply (well, river, etc.)?
® Number of pump/booster stations?
• How many miles of distribution pipeline?
3. Summarize the water treatment process employed:
4. Have you received any Notice of Violations (NOVs) within the past five (5) ❑ Yes ❑ No
years?
If yes, please explain:
5. Attach or provide a web link for most recent Customer Satisfaction Report.
6. Summarize your facility/water supply security:
California JPIA WTP Supplemental Page 9
Application (11/16)
California JPIA Application Pollution Application
Wastewater Treatment Plant (WWTP) Supplemental Application - N/A XX
Please read carefully and complete this supplemental application for each applicable
facility.
APPLICANT NAME:
1
WWTP Name:
Street Address:
City/State/Zip Code:
USEPA / State Identification Number:
2. WWTP Specifications:
• What year was the WWTP designed & built?
• Total Population serviced?
Design Capacity (gallons per day)?
Aver agevaiiuiiS pruceSSed per day?
• Does the facility accept industrial or pre-treated wastewater?
How does the plant dispose of bio-solids/sludge?
What is the discharge point for treated wastewater?
• Number of pump/lift stations?
• How many miles of sewer collection pipeline?
• What is the average age of the sewer collection pipeline system?
3. Summarize the wastewater treatment process employed:
4. Have you received any Notice of Violations (NOVs) and/or Odor Complaints ❑ Yes ❑ No
within the past five (5) years?
If yes, please explain:
5. Summarize any portions of the system that are combined sanitary/storm water lines.
6. Summarize your facility security:
California JPIA WTP Supplemental Page 10
Application (11/16)
California JPIA Application Pollution Application
RecyclingMaste FacilitV Supplemental Application - N/A X
Please read carefully and complete this supplemental application for each applicable
facility.
APPLICANT NAME:
1
Facility Name:
Street Address:
City/State/Zip Code:
USEPA / State Identification Number:
Type of Facility: Choose an item.
If Other, please
explain:
2. Recycling / Waste Facility Specifications:
• Is the Facility Operational or Closed?
• What year was the Facility designed & built?
• If Operational, what is the projected the Closure date?
• Design / Permitted Capacity?
• Average tons accepted per day?
• Total acres of property including buffer? (attach map)
• Disposal Area acres?
• What type of liner is used?
• Is there a leachate monitoring & collection system?
• Is there a methane gas monitoring & collection system?
3. Summarize the types of materials accepted by the Facility:
4. Are there any groundwater monitoring wells supporting the facility? ❑ Yes ❑ No
If yes, attach copies of monitoring results for the past year as well as a map showing the location of
each monitoring well, or provide a web link to documentation.
5. Have you received any Notice of Violations (NOVs) and/or Odor Complaints ❑ Yes ❑ No
within the past five (5) years?
If yes, please explain:
6. For Closed Landfills:
a. Have all closure requirements been met and an engineer's certificate issued? ❑ Yes ❑ No
b. Has the facility been inspected by any Federal/State agency of the USEPA? ❑ Yes ❑ No
If yes, please attach a copy of findings or web link to documentation.
California JPIA Recycling/Waste Page 11
Supplemental Application (11/16)
California JPIA Application Pollution Application
Airport Supplemental Application - N/A XX
Please read carefully and complete this supplemental application for each applicable
facility.
APPLICANT NAME:
1. Airport Name:
Street Address:
City/State/Zip Code:
2.
3
This Airport is for: ❑ General Aviation or ❑ Commercial Airport
Airport Specifications:
• What year did the airport begin operations?
• Total Acreage?
• Average number of flights daily?
Does the Airport contain a Fuel Farm?
If yes, please complete the following:
a. Who is responsible for maintaining the Fuel Tank Farm?
❑ Yes ❑ No
b. If Applicant does not operate and maintain the Fuel Tank Farm, what Pollution Liability
Insurance limits is the Operator required to carry?
C. If a fuel dispenser hydrant system is utilized, summarize the operational and integrity controls:
4. Does the Airport employ plane deicing operations?
If yes, please complete the following:
a. Who is responsible for performing the deicing?
b. Summarize the deicing process including location and chemicals employed:
c. Summarize the deicing runoff collection system:
5. Have you received any of Notice of Violations (NOVs) and/or Noise
Complaints within the past five (5) years?
If yes, please explain:
6. Summarize your facility security:
California JPIA Airport Supplemental
Application (11/16)
❑ Yes ❑ No
❑ Yes ❑ No
Page 12
California JPIA Application Pollution Application
Contracting Services Supplemental A2pfication - N/A XX
Please read carefully and complete this supplemental application.
APPLICANT NAME:
1. Does the Applicant perform Pesticide and/or Herbicide applications? ❑ Yes ❑ No
If yes, please complete the following:
a. Summarize method(s) of application:
b. Are all persons applying Pesticides and/or Herbicides certified? ❑ Yes ❑ No
c. Does Applicant maintain written protocols for chemical handling & application? ❑ Yes ❑ No
2. Does the Applicant have any Contracting Services exposure? ❑ Yes ❑ No
If yes, please complete the following:
a. Summarize the types of Services the Applicant performs on Non-Owned/Leased locations:
b. Does Applicant have written procedures in place to assure the One -Call ❑ Yes ❑ No
System is employed for all sub -grade work?
c. Does Applicant have written procedures in place regarding work in ❑ Yes ❑ No
contaminated areas?
3. Has the Applicant received any Notice of Violations (NOVs) within the past ❑ Yes ❑ No
five (5) years?
If yes, please explain:
4. Summarize any pollution conditions that the Applicant has caused during prior chemical
applications and/or while performing any Contracting Services:
California JPIA Contracting Services Page 13
Supplemental Application (11/16)
Indoor Air Quality Addendum
NOTE: This addendum forms a part of the original signed and executed application for this policy.
Named Insured
City of La Quinta
Polis No: EPC
Policy Term
1. Has any water or indoor air quality related construction/maintenance defects been
encountered (including but not limited to HVAC system problems, leaks in the roof,
windows or siding, as well as broken plumbing or sewer backups)?
If yes, what are they and how have they been addressed?
2. Any properties located in an area subject to periodic ponding or flooding?
If yes, when was the last time. the building was impacted by such ponding or flooding
and to what extent? What precautions are in place to mitigate future damage?
3. Have any indoor air quality/ mold studies or inspections been done?
If yes, please provide a copy.
4. Do any of the buildings' exterior walls have an Exterior Insulation Finish System (El FS)?
If yes, for each building, please complete the table below.
X No ❑ Yes
X No ❑ Yes
X No ❑ Yes
X No ❑ Yes
j Building Address I Age of EIFS System I Date of Last Inspection I Evidence of Water Intrusion
5. Have any of the buildings had mold growth in which remediation costs exceeded $25,000? X No ❑ Yes
If yes, please provide details.
Buildina Address I Location and Description of Mold Growth Total Costs for Remediation
6. Do you have a documented complaint procedure in place? ❑ No X Yes
7. Havc thcrc boon any third party complaints for indoor air quality / mold at any of the
covered locations? If yes, please complete the table below: X No ❑ Yes
Building Address I Incident Description Mitigation of Loss Total Costs for Incident
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8. At the time of the completion of this addendum, are you aware of any facts or
circumstances which may reasonably be expected to result in a Claim or Claims being
asserted against your company arising from indoor air quality/mold at the Covered Location? X No ❑ Yes
If yes, please provide details.
9. Please attach copies of the following relevant to the Covered Location(s) to which this addendum applies:
Water / Mold Operation and Maintenance Plan;
• 5 yrs. of Property and GL Loss Runs.
The applicant represents that all statements in this addendum are true and correct to the best of their knowledge and
that no material or relevant facts have been omitted, suppressed or misstated. The applicant represents that due
diligence has been conducted to know of the information listed on this addendum.
Namoi nsured's)put z d)signatur ? Printed name of authorized person
Angela Scott
Title: Date:
HR/Risk Manager 11/22/2019
Contact Person and Telephone Number E -Mail Address
Pam Nieto 760-777-7103 pnieto@laquintaca.gov
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