Insurance Certificates 2022/23 Jensen, SharlaINSURANCE REVIEW Cu �CU
-fAI11:0PNI!-
RE: Sharla Jensen Certificate of Liability Insurance, Additional Insured & Primary and
Noncontributory insurance documents for a new Instructor Agreement.
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
12-27-2022
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:
F—]$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:
F-1$1,000,000 per occurrence/loss
Other: Abuse & Molestation
List other insurance types such as - molestation, harassment, etc.
Approved by:
Date:
ACCO �®
�V�!� CERTIFICATE OF LIABILITY INSURANCE
DATE IYYYY)
12,27/2027,2022
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
CONTACT
NAME:
Next First Insurance Agency, Inc.
PO Box 60787
Palo Alto, CA 94306
PHONE (g55) 222-5919 FAX
A/C No Ext : A/C No),
E-MAIL ADDRESS: support@nextinsurance.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: State National Insurance Company, Inc.
12831
INSURED
INSURER B :
Sharla Jensen
Sharla Jensen
INSURER C :
INSURER D :
47750 Adams St Apt 513
La Quinta, CA 92253
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 922678875 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/DDIYYYY
POLICY EXP
MM/DDIYYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$2,000,000.00
CLAIMS -MADE � OCCUR
1A AGE TO TED
PREMIS lccurrrence)$100,000.00
SES (E. occurrence)
MED EXP (Any one person)
$15,000.00
PERSONAL & ADV INJURY
$1,000,000.00
A
X
NXTTK88QS1-02-GL
10/26/2022
10/26/2023
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$4,000,000.00
POLICY [:]PRO-JECT ❑ LOC
X
PRODUCTS - COMP/OP AGG
$2,000,000.00
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
L
$
UMBRELLALIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER OTH-
STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
N/A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
Each Occurrence:
$2,000,000.00
A
Professional Liability
NXTTK88QS1-02-GL
10/26/2022
10/26/2023
Aggregate:
$4,000,000.00
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is City of La Quinta. This Certificate Holder is an Additional Insured on the General Liability policy on a primary and non-contributory basis. All Certificate
Holder privileges apply only if required by written agreement between the Certificate Holder and the insured, for Personal Trainer for both adults and minors services at
78-495 Calle Tampico, La Quinta, CA 92253 location subject to policy terms and conditions.
CERTIFICATE HOLDER CANCELLATION
City of La Quinta LIVE CERTIFICATE
78-495 Calle Tampico
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
La Quinta, CA 92253
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
•r•
AUTHORIZED REPRESENTATIVE
❑M T.
Click or scan to view
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number 02
POLICY NUMBER
POLICY CHANGES
COMPANY
EFFECTIVE
NXTTK88QS1-02-GL
12/27/2022
State National Insurance Company, Inc.
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Sharla Jensen
Sharla Jensen
47750 Adams St Apt 513
Eric Hamden
La Quinta, CA 92253
COVERAGE PARTS AFFECTED
Commercial General Liability Coverage Part
CHANGES
SEE ATTACHED SCHEDULE
Return Total $0.00
4/70;�
Authorized Representative Signature
IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 2 ❑
Copyright, ISO Commercial Risk Services, Inc., 1983
I SCHEDULE OF POLICY CHANGES I
It is understood and agreed that:
The following forms are added:
NXT-0084 BM GL 0218 - Designated Additional Insured - Primary Insurance
other terms and conditions remain unchanged.
IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 ❑
Copyright, ISO Commercial Risk Services, Inc., 1983
COMMERCIAL GENERAL LIABILITY
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:
City of La Quinta, it officers, agents, and employees
78-495 Calle Tampico
La Quinta, CA 92253
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.
NXT-0084 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 1
permission
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 —7S� Ig e t-4 as follows:
I am the authorized representative of --A li C tA-
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
)± i� r ,. f r -- A" . 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
47
Date Authorized Repti5sentative
Declaration Regarding California Workers' Compensation
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:/Iwww.dir.ca..ov.
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
awLlinitial) California Labor Code § 3700 requires employers to carry workers' compensation
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.
J{ (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.
S (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.
S I(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.
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 Declar t
sh hg L,9� �J P t-LS
Print Name of Declarant
Print Name of Company