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Insurance Certificates 2020/21 Frizzell, NateINSURANCE 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: ________________________ Insurance for Art Purchase Agreement with Nate Frizzell for a mural on the intersection of Fred Waring Drive and Adams Street, for $13,500. 11/3/2020 Proof of Insurance. 12831State National Insurance Company, Inc. X NXT9MEI791-01-GL 1,000,000.00 Nate Frizzell Nate Frizzell 2526 Virginia Rd Los Angeles, CA 90016 2,000,000.00 2,000,000.00 5,000.00 100,000.00 1,000,000.00 09/19/202109/19/2020 X X X A 1393938 support@nextinsurance.com (855) 222-5919 Nate Frizzell Nate Frizzell 2526 Virginia Rd Los Angeles, CA 90016 Next First Insurance Agency, Inc. PO Box 60787 Palo Alto, CA 94306 10/02/2020 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY $0.00Additional Total Commercial General Liability Coverage Part Ann Ryan Nate Frizzell 2526 Virginia Rd Los Angeles, CA 90016 State National Insurance Company, Inc.11/03/2020NXT9MEI791-01-GL 05 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Copyright, ISO Commercial Risk Services, Inc., 1983 Page 1 of † POLICY CHANGES Policy Change Number POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY NAMED INSURED AUTHORIZED REPRESENTATIVE COVERAGE PARTS AFFECTED CHANGES Authorized Representative Signature 6(($77$&+('6&+('8/( It is understood and agreed that: The following forms are added: NXT-0084 BM GL 0218 - Designated Additional Insured - Primary Insurance CG 20 10 04 13 - Additional Insured - Owners, Lessees or Contractors - Scheduled Person or Organization CG 20 37 04 13 - Additional Insured - Owners, Lessees or Contractors - Completed Operations All other terms and conditions remain unchanged. 6&+('8/(2)32/,&<&+$1*(6 IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Copyright, ISO Commercial Risk Services, Inc., 1983 Page  of † City of La Quinta Certificate Holder 78495 Calle Tampico La Quinta, CA 92253 COMMERCIAL GENERAL LIABILITY NXT-0084 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its permission Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED – PRIMARY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person or Organization: I.SECTION II - WHO IS AN INSURED is amended to include the person or organization 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 you r 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. II.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. III.Coverage provided to the additional insured shown in the SCHEDULE is afforded on i) a primary basis, ii) a noncontributory basis, or iii) a primary and noncontributory basis in accordance with the applicable written contract between you and the additional insured. All other terms and conditions of the policy remain unchanged. CACity of La Quinta Certificate Holder 78495 Calle Tampico La Quinta, CA 92253 NXT9MEI791-01-GLPOLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED 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) Location(s) Of Covered Operations 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 C. 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. Fine Artists, Including Painters, Sculptors, and Illustrators services in CA City of La Quinta Certificate Holder 78495 Calle Tampico La Quinta, CA 92253 NXT9MEI791-01-GLPOLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". 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. DeclaƌaƚiŽn Regaƌding CalifŽƌnia WŽƌkeƌƐ͛ CŽmƉenƐaƚiŽn You are required to complete this form because you have not filed a certificate regarding workers' compensation insurance with City of La Quinta. California law requires all employers to carry workers' compensation insurance, even if they have only one employee. If you do not know whether you are required to carry workers' compensation insurance, find out by contacting the California Department of Industrial Relations ("DIR"). Information is also available on the DIR's website at http://www.dir.ca.gov. You should also consult with your attorney, insurance agent or broker, or carrier regarding the specifics of your situation and your options. If you are subject to the Workers' Compensation Laws of California, you must promptly file a certificate of Workers' Compensation Insurance with City of La Quinta. If you have a certificate of self-insurance from the DIR, you must file that certificate with City of La Quinta. When completing this form, remember that the term "employee" includes clerical persons as well as any other persons employed by your company including drivers. ACKNOWLEDGMENT _____(initial) California Labor Code § 3700 requires employers to carry wŽƌkeƌƐ͛ cŽmƉenƐaƚiŽn insurance or to obtain a certificate from the Director of Industrial Relations demonstrating that the employer is self-insured. California Labor Code § 3700.5 makes it a criminal offense for an employer to fail to secure compensation as required by the workers' compensation provisions of the Labor Code. Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to one year. _____(initial) California Labor Code § 3710.1 provides that where an employer fails to provide compensation required under § 3700, the Director of the Department of Industrial Relations shall issue a stop order, prohibiting the employer from using employee labor until such time as the employer complies with the provisions of § 3700. Labor Code § 3710.2 makes it a criminal offense to disregard such stop orders. _____(initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' Compensation Laws of California. _____(initial) I understand that California Labor Code § 3700 et seq. requires employers to provide workers' compensation insurance coverage for any employees of my business. I hereby warrant that this business is exempt from the California Labor Code provisions regarding workers' compensation insurance because it has no employees. _____(initial) I agree to hold City of La Quinta and its officers, officials, employees, and agents harmless for loss or liability which may arise from the failure of my business to comply with the laws of the State of California regarding workers' compensation insurance. _____(initial) If I hire employees in the future, I will immediately notify City of La Quinta and provide a certified Workers' Compensation certificate to the City. NF NF NF NF NF NF CERTIFICATION I (we) certify under penalty of perjury, under the laws of the State of California, that I (we) have read and understood the above stated requirements regarding Workers' Compensation and that I(we) am (are) in compliance. I(we) certify that the forgoing is true and correct. Executed this ____________ day of _____________ 20___ at ____________________, California _____________________________________ Signature of Declarant _____________________________________ Print Name of Declarant _____________________________________ Print Name of Company 9th Nov Los Angeles Nate Frizzell Nate Frizzell 20 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 _________________________________________________________ as follows: I am the authorized representative of _______________________________________________, an independent contractor fRU Whe SXUSRVeV Rf Whe CaOifRUQia WRUkeUV¶ CRPSeQVaWiRQ aQd LabRU 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 ______________________________________________________. 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 WheUeRf, Whe RUgaQi]aWiRQ VhaOO RbWaiQ WRUkeUV¶ CRPSeQVaWiRQ IQVXUaQce aQd SURYide SURRf Rf WRUkeUV¶ CRPSeQVaWiRQ IQVXUaQce cRYeUage WR Whe City of La Quinta. If the organization shall ever hire a subcontractor to perform this contract or any portion thereof, and the subcontractor haV ePSOR\eeV, WheQ Whe RUgaQi]aWiRQ VhaOO UeTXiUe iWV VXbcRQWUacWRU WR RbWaiQ WRUkeUV¶ Compensation Insurance Coverage, or the organiz aWiRQ VhaOO RbWaiQ WRUkeUV¶ CRPSeQVaWiRQ CRYeUage fRU WhaW VXbcRQWUacWRU¶V ePSOR\eeV. This document constitutes a declaration by the organization against its financial interest, relative WR aQ\ cOaiPV iW VhRXOd aVVeUW XQdeU Whe CaOifRUQia WRUkeUV¶ CRPSeQVation and/or Labor laws against City of La Quinta relating 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 liabiOiW\, iQcOXdiQg WRUkeUV¶ CRPSeQVaWiRQ cOaiPV aQd OiabiOiW\ WhaW Pa\ be asserted or established by any party 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 Authorized Representative Nate Frizzell Nate Frizzell Nate Frizzell Nate Frizzell Nate Frizzell 11/9/20 Nate Frizzell Digitally signed by Nate Frizzell Date: 2020.11.09 17:56:34 -08'00' CALIFORNIA PROOF OF FINANCIAL RESPONSIBILITY CARD INFINITY INSURANCE COMPANY Year Make / Model Vehicle ID Number Driver 2002 Isuz / Axiom 4S2DF58X124600217 Nathan Frizzell Policy Number NAIC Name & Address of Insured 104601017034001 22268 Nathan Frizzell 5649 Eveningside Ln Riverside, CA 92509 Effective Date 09/19/2020 Expiration Date 09/19/2021 THIS CARD SHOULD BE KEPT IN THE VEHICLE WITH THE VEHICLE'S REGISTRATION CARD AT ALL TIMES _ F O L D H E R E _ CALIFORNIA INSUREDS THIS CALIFORNIA PROOF OF FINANCIAL RESPONSIBILITY CARD IS PROVIDED FOR YOUR USE TO ENABLE YOU TO COMPLY WITH SECTION 16028 OF THE CALIFORNIA VEHICLE CODE WHICH BECAME EFFECTIVE JULY 1, 1985 AND WHICH READS IN PART: 16028(a) Every person who drives a motor vehicle required to be registered in this state upon a highway shall, when requested by a peace officer, provide evidence of financial responsibility for the vehicle. One of the definitions of "evidence of financial reponsibility" reads in part: (A) The name of the insurance company which issued the autombile liability policy, in effect for the vehicle and the number of the insurance policy. SHOW THIS CARD TO THE REQUESTING PEACE OFFICER WHEN ASKED TO PROVIDE EVIDENCE OF FINANCIAL RESPONSIBILITY. X _________________________________________ IF YOU ARE INVOLVED IN AN ACCIDENT REPORT YOUR LOSS IMMEDIATELY PHONE: 1-800-334-1661 7 DAYS A WEEK / 24 HOURS A DAY