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Insurance Certificates 2021/22 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: ________________________ Art Purchase Agreement with Nate Frizzell for Cultural Campus mural. 11/4/21 ✔ ✔ ✔ ✔ ✔ ✔ Monika Radeva 11/9/2021 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/04/2021 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 Next First Insurance Agency, Inc. PO Box 60787 Palo Alto, CA 94306 CONTACT NAME: PHONE (855) 222-5919 (A/C, No, Ext): FAX (A/C, No): E-MAIL support@nextinsurance.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : State National Insurance Company, Inc. 12831 INSURED Nate Frizzell Nate Frizzell 2526 Virginia Rd Los Angeles, CA 90016 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 4186418 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 A X COMMERCIAL GENERAL LIABILITY X NXT9MEI791-02-GL 09/19/2021 09/19/2022 EACH OCCURRENCE $ 1,000,000.00 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00 X POLICY PRO- LOC JECT OTHER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON-OWNED AUTOS ONLY BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of La Quinta, its officers, officials, employees and agents are Additional Insured on the General Liability policy f or ongoing operations, on a primary and non-contributory basis if required by written agreement between the Certificate Holder and the insured. Separately, Certificate Holder is an Additional Insured on the General Liability policy with respect to completed operations. All Certificate Holder privileges are subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Evidence of Insurance Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. NATHAN CHARLES FRIZZELL 4925 LOCOMOTIVE LN RIVERSIDE CA 92504 California Evidence of Liability Insurance 1-800-841-3000 GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 41491 Policy Number Effective Date Expiration Date 6086-03-31-12 11-06-21 05-06-22 Year Make Model Vehicle ID No. 2002 ISUZU AXIOM/XS 4S2DF58X124600217 Insured: Nathan Charles Frizzell 4925 Locomotive Ln Riverside CA 92504 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. California Evidence of Liability Insurance 1-800-841-3000 GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 41491 Policy Number Effective Date Expiration Date 6086-03-31-12 11-06-21 05-06-22 Year Make Model Vehicle ID No. 2002 ISUZU AXIOM/XS 4S2DF58X124600217 Insured: Nathan Charles Frizzell 4925 Locomotive Ln Riverside CA 92504 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. $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 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. 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. 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 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 ______________________________________________________. 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 organiz ation 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 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 liability, including Workers’ Compensation claims and liability that may 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 Nate Frizzell 2/16/22 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 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 ______________________________________________________. 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 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 liability, including Workers’ Compensation claims and liability that may 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 1DWH)UL]]HOO 1DWH)UL]]HOO 1DWH)UL]]HOO 1DWH)UL]]HOO 1DWH)UL]]HOO 1DWH)UL]]HOO