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DTA ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 4/21/2022 (909) 484-2456 11000 David Taussig & Associates Inc. dba: DTA 5000 Birch St. Suite #3000 Newport Beach, CA 92660 38342 19445 34690 18058 19682 A 2,000,000 X 72SBAAP5439 2/24/2022 2/24/2023 1,000,000 10,000 2,000,000 4,000,000 4,000,000 1,000,000B BA040000030599 12/8/2021 12/8/2022 5,000,000C EBU084786479 2/24/2022 2/24/2023 5,000,000 D X 72WECEU2873 9/1/2021 9/1/2022 1,000,000 1,000,000 1,000,000 E Prof. Liab/Claims PHSD1669825 11/1/2021 Per Claim Limit 2,000,000 F Crime 72 BDD HP8140 6/14/2021 6/14/2022 1,000,000 G..L. RENEWAL ONLY. ALL PREVIOUSLY ISSUED A.L. AND W.C. ENDORSEMENTS ARE STILL VALID. CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED. -A/I WITH PRIMARY WORDING AND W.C. WAIVER ATTACHED. CITY OF LA QUINTA ATTN: DIANNE HANSEN, MANAGEMENT ANALYST 78495 CALLE TAMPICO La Quinta, CA 92253 DAVITAU-01 LBURRILL Southern California Insurance Brokerage 3110 E. Guasti Road Suite 500 Ontario, CA 91761 Lisa Burrill lisa@socalinsurance.com Sentinel Insurance Company, Ltd California Automobile Insurance Company National Union Fire Insurance Company of Pittsburgh, Pa. Property and Casualty Insurance Company of Hartford Philadelphia Indemnity Insurance Company Hartford Fire Insurance Company X 11/1/2022 X X X X X X !" #$% &’$ !$( !"! ) ) * #$% +," "## $%(-(! +," ..!$/ !"! #&&’ ( )&( & *’ - (+- (- --"+,)+ -). /+ 0)-#1 )/ 2 3)4 - -# % /#"0- 3#4 ! 55 " ’ ( &( ** &6 ’ *’ " 7** &’ ( ’* - ( * * 8 &( 79 7 ’’ : ( &( ; ( ( ** ’ ’’* ( & (* 7* 79 ’ ’* - * (( & ( ** < & *& 79= ’( (( 7 ’ ( ( 0 ($1 !$(2, $’!$( & 7( : 7 ’’ ( 7 & &( Page 9 of 47 ATTACHMENT 2 INSURANCE REQUIREMENTS ACKNOWLEDGEMENT Must be executed by proposer and submitted with the proposal I, ________________________________________ (name) hereby acknowledge and confirm that __________________________________ (name of company) has reviewed the City’s indemnification and minimum insurance requirements as listed in Exhibits E and F of the City’s Agreement for Contract Services (Attachment 1); and declare that insurance certificates and endorsements verifying compliance will be provided if an agreement is awarded. I am _________________________________ of ______________________________, (Title) (Company) Commercial General Liability (at least as broad as ISO CG 0001) $1,000,000 (per occurrence); $2,000,000 (general aggregate) Must include the following endorsements: General Liability Additional Insured General Liability Primary and Noncontributory Commercial Auto Liability (at least as broad as ISO CA 0001) $1,000,000 (per accident) Personal Auto Declaration Page if applicable Errors and Omissions Liability $1,000,000 (per claim and aggregate) Worker’s Compensation (per statutory requirements) Must include the following endorsements: Worker’s Compensation Waiver of Subrogation Worker’s Compensation Declaration of Sole Proprietor if applicable Page 10 of 47 ATTACHMENT 3 NON-COLLUSION AFFIDAVIT FORM Must be executed by proposer and submitted with the proposal I, ________________________________________ (name) hereby declare as follows: I am _________________________________ of ______________________________, (Title) (Company) the party making the foregoing proposal, that the proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the proposal is genuine and not collusive or sham; that the proposer has not directly or indirectly induced or solicited any other proposer to put in a false or sham proposal, and has not directly or indirectly colluded, conspired, connived, or agreed with any proposer or anyone else to put in a sham proposal, or that anyone shall refrain from proposing; that the proposer has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the proposal price of the proposer or any other proposer, or to fix any overhead, profit, or cost element of the proposal price, or of that of any other proposer, or to secure any advantage against the public body awarding the agreement of anyone interested in the proposed agreement; that all statements contained in the proposal are true; and, further, that the proposer has not, directly or indirectly, submitted his or her proposal price or any breakdown there of, or the contents thereof, or divulged information or data relative hereto, or paid, and will not pay, any fee to any corporation, partnership, company, association, organization, proposal depository, or to any member or agent thereof to effectuate a collusive or sham proposal. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Proposer Signature: __________________________________________________ Proposer Name: __________________________________________________ Proposer Title: __________________________________________________ Company Name: __________________________________________________ Address: __________________________________________________ Page 11 of 47 ATTACHMENT 4 ACKNOWLEDGEMENT OF RECEIPT OF ADDENDA Must be executed by proposer and submitted with the proposal; If no addenda has been issued, mark “N/A” under Addendum No. indicating Not Applicable and sign ADDENDUM NO. SIGNATURE INDICATING RECEIPT