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Insurance Certificates 2022/23 Novak, Janr RE: INSURANCE REVIEW Cv itlK.rCv CALIFORNIA Jan Novak, Instructor Agreement (FY 22-23) for Pickleball instructor to be performed at Fritz Burns Park 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 12/30/2022 with Acord 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: Approved by: Date: List other insurance types such as - molestation, harassment, etc. Monika Radeva 12/30/2022 7B495 Calle Tampico 1 La (Onfa, California 92253 1160.m./0001 www.laquinfaca.gov / ACCORD® � D® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/30/2022 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 Correll Insurance Group of Hilton Head PO Box 6869 Hilton Head Island SC 29938 CONTACT Michele Reitz NAME: PHONE NN FAX , EXtt: (843) 785-7733 FNo): E-MAIL mreitz@correllhhi.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Philadelphia Indemnity 18058 INSURED Professional Tennis Registry, Inc. Professional Pickleball Registry, Inc. Professional Platform Tennis Registry, Inc. / P. O. Box 4739 Hilton Head Island SC 29938 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: PTR PPR Blank 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 PHPK2443121 09/01/2022 09/01/2023 EACH OCCURRENCEDAMAGE $ 1,000,000 CLAIMS -MADE X OCCUR TO RETED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PRO PER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE PHUB825358 09/01/2022 09/01/2023 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N NIA 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) [Job #: 772 Job Type: ] 128779 - Certificate Holder is listed as Additional Insured # 772 with respect to Member # 128779 - Jan Novak , 53480 Avenida Juarez , La Quinta CA 92253 CERTIFICATE HOLDER CANCELLATION City of La Quinta 78495 Calle Tampico La Quinta I 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 1WV4-- �~ ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds ; Professional Pickleball Registry, Inc.; Professio Doing Business As PTR Doing Business As OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC PI-GL-005 (07/12) 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 Effective Date: 09/01/2022 PHPK2443121 Name of Person or Organization (Additional Insured): City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 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. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: PHPK2443121 COMMERCIAL GENERAL LIABILITY CG20260413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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): City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 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. CG20260413 © Insurance Services Office, Inc., 2012 Page 1 of 1 INSURANCE 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: ________________________ Jan Novak, Instructor Agreement (FY 22-23) for Pickleball instructor to be performed at Fritz Burns Park. 4-28-2022 with Alliant ✔ ✔ ✔ Monika Radeva 6/25/2022 Jan Novak -B2VJOUB EVANSTON INSURANCE COMPANY CERTIFICATE NO. CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with Apex Insurance Services P. O. Box 6450 Newport Beach,CA 92658 License No: OC 36861 CITY OF LA QUINTA 78-495 CALLE TAMPICO LA QUINTA, CA 92253 NAMED INSURED (EVENT HOLDER): -$1129$. $9(1,'$-8$5(= LA QUINTA, CA 92253 EVENT INFORMATION: TYPE:3,&./(%$//,16758&7,21 DATE(S):WR LOCATION:LA QUINTA WELLNESS CENTER)5,7=%85163$5. *Liquor Liability Yes No X **Liquor Liability after 12 am ends before 2 am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the p olicy period indicated.The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies)unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: MASTER POLICY DATES:EFFECTIVE: JANUARY 1, 202EXPIRATION:-$18$5< COMMERCIAL GENERAL LIABILITY General Aggregate Limit Products & Completed Operations Personal & Advertising Injury Each Occurrence Limit Damage To Premises Rented To You (Any One Premises) Medical Payments (Any One Person) Liquor Liability (If purchased) Optional Limits Purchased $1,000,000/$3,000,000 $2,000,000/$2,000,000 Damage To Property (If purchased) $ 2,000,000 1,000,000 1,000,000 1,000,000 100,000 5,000 1,000,000 OCCURRENCE FORM DEDUCTIBLE: NONE SPECIAL CONDITIONS: The following endorsements attached to the Master Policy do not apply to this Certificate Of Insurance: MEGL643 The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS CANCELLATION:Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED:  MKLV7PBC000935 © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 11 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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 arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1.Any "occurrence" which takes place after you cease to be a tenant in that premises. 2.Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. 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. COMMERCIAL GENERAL LIABILITY CG 20 11 04 13 Designation Of Premises (Part Leased To You): Name Of Person(s) Or Organization(s) (Additional Insured): Additional Premium:Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Member organizations of the Special Events Liability Program, including the Directors, Officers, Employees, and Agents of the member organization All Premises POLICY NUMBER: MKLV7PBC000935 © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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. COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 POLICY NUMBER: MKLV7PBC000935 Per each Certificate of Insurance, as applicable Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Name Of Additional Insured Person(s) Or Organization(s): MEGL 1857 08 14 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1of 1 COMMERCIAL GENERAL LIABILITY EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTING INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is added to the Other Insurance Condition and supersedes and provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to any public entity that is a Named Insured or is named as an additional insured under your policy. All other terms and conditions remain unchanged.