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Insurance Certificates 2023/24 Love & Love Tennis Foundation Volunteer OrgSave Entered Data / ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 1 08/17/2023 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: Cliff Cottam Insurance Services S&G Mitchell Insurance Agency, Inc. FA a/cNN Ext : 916-488-4426 A/C No), E-MAIL vardette vfardette@mitchellandmitchell.com ADDRESS: C Douglas Blvd. Ste 100 3013 Dou 9 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: United States Liability Ins. 25895 Roseville CA 95661 INSURED INSURER B : INSURER C The Love & Love Tennis Foundation INSURER D The Love & Love Tennis Foundation INSURER E : 810 Snow Creek Cyn 1 INSURER F : Palm Desert CA 92211-8993 COVERAGES CERTIFICATE NUMBER: 1555 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 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y N NPP1590427D 08/01/2023 08/01/2024 EACH OCCURRENCE $ 1,000,000 DAMAGE PREM SES� a o_cur RENTEence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- ❑ LOC JECT OTHER: GENERAL AGGREGATE $ X PRODUCTS-COMP/OPAGG $ 2,000,000 $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY L COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 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 OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of La Quinta is named additional insured per attached and Primary non-contributory status applis. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of La Quinta ACCORDANCE WITH THE POLICY PROVISIONS. 78495 Calle Tampico AUTHORIZED REPRESENTATIVE La Quinta CA 92253 ©1988-2015 ACORD C01750RATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM BLANKET ADDITIONAL INSURED ENDORSEMENT Section II — Who Is An Insured is amended to include as an insured any person, entity or organization that is: 1. A franchisor under a franchise agreement with the Named Insured as franchisee relating to "your work"; or 2. A licensor under a license agreement with the Named Insured as licensee relating to "your work"; or 3. A co-owner with the Named Insured in premises used for "your work"; or 4. A majority owner with a controlling interest in the Named Insured but only with respect to liability arising out of such owner's (i) financial or operational control of the Named Insured; or (ii) ownership, maintenance or use of premises leased or occupied by the Named Insured for purposes of "your work"; or 5. A mortgagee, assignee or receiver of the Named Insured relating to "your work"; or 6. A lessor, or an agent of a lessor, under a lease agreement with the Named Insured as lessee relating to "your work"; or 7. A grantor of a permit to the Named Insured as permitee relating to "your work". However, if the grantor of a permit is a federal, state or local government or political subdivision, there is coverage under this endorsement only for liability arising from: a. The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or b. The construction, erection or removal of elevators; or c. The ownership, maintenance or use of any elevators covered by this insurance; or 8. A lessor of equipment leased to the Named Insured relating to "your work"; or 9. A contributor, benefactor, or supporter who provides financial assistance to the Named Insured in connection with "your work"; but only to the extent the Named Insured is required to add such person, entity or organization as an additional insured to this policy under a written contract, written permit or written agreement relating to "your work". Such person, entity or organization is an insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" that is caused, in whole or in part by your acts or omissions or the acts or omissions of those acting on your behalf in connection with "your work" while such written contract, written permit or written agreement is in effect. L 744 N P P (06-10) Page 1 of 2 EXCLUSIONS There is no coverage under this endorsement for loss or expense, including but not limited to the cost of defense for "bodily injury", "property damage" or "personal and advertising injury": I. That occurs after all of "your work", including materials, parts or equipment furnished in connection with "your work" and performed under a written contract, written permit or written agreement has ended; or When that portion of "your work" out of which the "bodily injury", "property damage" or "personal and advertising injury" arises and performed under a written contract, written permit or written agreement has been put to its intended use by any person(s) or organization(s); whichever occurs first. 2. Arising directly or indirectly from construction or demolition operations of any kind performed by you. 3. Caused or alleged to be caused by the sole negligence of an additional insured under this endorsement. 4. Arising out of "your work" performed for a federal, state or local government or political subdivision under a written permit. 5. Included within the "products -completed operations hazard". CONDITIONS Coverage provided by this endorsement will be excess over any insurance available to any additional insured under this endorsement unless a written contract, written permit or written agreement specifically requires that coverage under this endorsement is primary. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 744 N P P (06-10) Page 2 of ENDORSEMENT #1 This endorsement, issued by United States Liability Insurance Company to THE LOVE & LOVE TENNIS FOUNDATION forms a part of Policy Number NPP1590427C effective on 5/25/2023 (MO. DAY YR.) at 12:01 A.M. Add/Remove/Amend General Liability Additional Insured Endorsement In consideration of no change in premium it is hereby agreed that the following form(s) is(are) added to the Policy: L-776 10/13 - Primary And Non -Contributory - Written Contract All other terms and conditions of this Policy remain unchanged. ADD —REM (03-01) UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Primary And Non -Contributory - Written Contract Name of Person or Organization: Effective Date: 05/25/2023 12:01 AM CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4. OTHER INSURANCE, a. Primary Insurance is amended with the addition of the following: The coverage afforded by this policy to the person(s) or organization(s) listed above is primary and non- contributory if: 1. This insurance is required to be primary and non-contributory under a written contract; and 2. The loss to be covered occurs on or after the effective date of the written contract; and 3. The loss to be covered resulted solely and exclusively from your ongoing acts or omissions or the ongoing acts or omissions of those acting on your behalf in performing "your work" under a written contract referred to above. 4. The person(s) or organization(s) is an additional insured under this policy. However, the coverage provided by this endorsement does not apply to any coverage provided for an "auto' on a "non -owned auto', "hired auto', uninsured motorists coverage, underinsured motorists coverage, personal injury protection, property protection or similar no-fault coverage by whatever name called and/or an "auto' coverage of any type. SECTION V - DEFINITIONS is hereby amended by the addition of the following: "Hired auto" means any "auto' you lease, hire, rent or borrow. This does not include any "auto' you lease for a period of more than thirty (30) consecutive days nor does it include any "auto' you lease, hire, rent or borrow from any of your "employees", your partner or your "executive officers" or members of their household. "Non -owned auto" means any "auto' you do not own, lease, hire, rent or borrow which is used in connection with your business. However, if you are a partnership, a "non -owned auto' does not include any "auto' owned by any partner. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 776 (10-13) Page 1 of it RE: INSURANCE REVIEW Cv itlK.rCv CALIFORNIA Insurance for Love and Love Tennis Foundation (501c3) offerring FREE tennis lessons for children 7 - 17 years of age at the La Quinta 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 05/22/2023 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 6/2/2023 7B495 Calle Tampico 1 La (Onfa, California 92253 1160.m./0001 www.laquinfaca.gov ACORO® CERTIFICATE OF LIABILITY INSURANCE ilks.....----- DATE (MM/DDIYYYY) 05/22/2023 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 S&G Mitchell Insurance Agency, Inc. Douglas Blvd. Ste 100 3013 Dou g Roseville CA 95661 CONTACT NAME: Cliff Cottam Insurance Services PHONE o, E,�): 916-488-4426 FAX No): E-MAIL varette vfardette@mitchellandmitchell.com ADDRESS: CC INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: United States Liability Ins. 25895 INSURED The Love & Love Tennis Foundation The Love & Love Tennis Foundation 810 Snow Creek Cyn Palm Desert CA 92211-8993 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1483 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. INSRTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERALLIABILITY Y N NPP1590427C 08/01/2022 08/01/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE TRENTED PREMISESO(Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 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 ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N 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) City of La Quinta is named additional insured per attached and Primary non-contributory status applis. 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 ' �/ ..���,� //� PG�2.e:exC.C.� ACORD 25 (2016/03) © 1988-2015 ACORD CO ORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM BLANKET ADDITIONAL INSURED ENDORSEMENT Section II — Who Is An Insured is amended to include as an insured any person, entity or organization that is: 1. A franchisor under a franchise agreement with the Named Insured as franchisee relating to "your work"; or 2. A licensor under a license agreement with the Named Insured as licensee relating to "your work"; or 3. A co-owner with the Named Insured in premises used for "your work"; or 4. A majority owner with a controlling interest in the Named Insured but only with respect to liability arising out of such owner's (i) financial or operational control of the Named Insured; or (ii) ownership, maintenance or use of premises leased or occupied by the Named Insured for purposes of "your work"; or 5. A mortgagee, assignee or receiver of the Named Insured relating to "your work"; or 6. A lessor, or an agent of a lessor, under a lease agreement with the Named Insured as lessee relating to "your work"; or 7. A grantor of a permit to the Named Insured as permitee relating to "your work". However, if the grantor of a permit is a federal, state or local government or political subdivision, there is coverage under this endorsement only for liability arising from: a. The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or b. The construction, erection or removal of elevators; or c. The ownership, maintenance or use of any elevators covered by this insurance; or 8. A lessor of equipment leased to the Named Insured relating to "your work"; or 9. A contributor, benefactor, or supporter who provides financial assistance to the Named Insured in connection with "your work"; but only to the extent the Named Insured is required to add such person, entity or organization as an additional insured to this policy under a written contract, written permit or written agreement relating to "your work". Such person, entity or organization is an insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" that is caused, in whole or in part by your acts or omissions or the acts or omissions of those acting on your behalf in connection with "your work" while such written contract, written permit or written agreement is in effect. L 744 NPP (06-10) Page 1 of2 EXCLUSIONS There is no coverage under this endorsement for loss or expense, including but not limited to the cost of defense for "bodily injury", "property damage" or "personal and advertising injury": 1. That occurs after all of "your work", including materials, parts or equipment furnished in connection with "your work" and performed under a written contract, written permit or written agreement has ended; or When that portion of "your work" out of which the "bodily injury", "property damage" or "personal and advertising injury" arises and performed under a written contract, written permit or written agreement has been put to its intended use by any person(s) or organization(s); whichever occurs first. 2. Arising directly or indirectly from construction or demolition operations of any kind performed by you. 3. Caused or alleged to be caused by the sole negligence of an additional insured under this endorsement. 4. Arising out of "your work" performed for a federal, state or local government or political subdivision under a written permit. 5. Included within the "products -completed operations hazard". CONDITIONS Coverage provided by this endorsement will be excess over any insurance available to any additional insured under this endorsement unless a written contract, written permit or written agreement specifically requires that coverage under this endorsement is primary. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 744 NPP (06-10) Page 2 of2 ENDORSEMENT #1 This endorsement, issued by United States Liability Insurance Company to THE LOVE & LOVE TENNIS FOUNDATION forms a part of Policy Number NPP1590427C effective on 5/25/2023 (MO. DAY YR.) at 12:01 A.M. Add/Remove/Amend General Liability Additional Insured Endorsement In consideration of no change in premium it is hereby agreed that the following form(s) is(are) added to the Policy: L-776 10/13 - Primary And Non -Contributory - Written Contract All other terms and conditions of this Policy remain unchanged. ADD_REM (03-01) UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Primary And Non -Contributory - Written Contract Name of Person or Organization: Effective Date: 05/25/2023 12:01 AM CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4. OTHER INSURANCE, a. Primary Insurance is amended with the addition of the following: The coverage afforded by this policy to the person(s) or organization(s) listed above is primary and non- contributory if: 1. This insurance is required to be primary and non-contributory under a written contract; and 2. The loss to be covered occurs on or after the effective date of the written contract; and 3. The loss to be covered resulted solely and exclusively from your ongoing acts or omissions or the ongoing acts or omissions of those acting on your behalf in performing "your work" under a written contract referred to above. 4. The person(s) or organization(s) is an additional insured under this policy. However, the coverage provided by this endorsement does not apply to any coverage provided for an "auto" on a "non -owned auto", "hired auto", uninsured motorists coverage, underinsured motorists coverage, personal injury protection, property protection or similar no-fault coverage by whatever name called and/or an "auto" coverage of any type. SECTION V - DEFINITIONS is hereby amended by the addition of the following: "Hired auto" means any "auto" you lease, hire, rent or borrow. This does not include any "auto" you lease for a period of more than thirty (30) consecutive days nor does it include any "auto" you lease, hire, rent or borrow from any of your "employees", your partner or your "executive officers" or members of their household. "Non -owned auto" means any "auto" you do not own, lease, hire, rent or borrow which is used in connection with your business. However, if you are a partnership, a "non -owned auto" does not include any "auto" owned by any partner. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 776 (10-13) Page 1 of 1 Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO 7 Love ' LOYc TCKN+s rwuN D#'-norms Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to CO 1 WJ6- TNwLS �vJrv��rLJ rJ as follows: I am the authorized representative of i 4- j O if + Lo J ( CNN t , 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 'R-ta Lo JE 4- GOVC r J, i t C FOUNo, Tzvrl . 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 f o' Ldl e Lov6 ( .coon . 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 constitutc an addendum to any bid or contracts awarded to AS-WZc, Date Auth Representative 12•5 e c et- sa is 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 ❑IR'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. A . NOWLEDGMENT (initial) California Labor Code § 3700 requires employers to carry workers' compensation in urance 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 ear. (initial) California Labor Code § 3710.1 provides that where an employer fails to provide co ti ensation 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 wi"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 w ers' 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 ss 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 cer ed 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. [(we) certify that the forgoing is true and correct. Executed this o-s day of 20at ?idC A& [3 e4 , California ■r � Signatut Declarant DS l CA-SA'l.�i Print Name of Declarant it l'E Lo,1f i 10,16 j tkrPir s vn d cl've Print Name of Company