Insurance Certificates 2023/24 Desert Pickleball LeaguebL
INSURANCE REVIEW Cu �Cu
CALIFORNIA
RE: Coachella Valley Grand Prix Tennis, LLC DBA Desert Pickleball League
Certificate of Liability Insurance, Additional Insured & Primary and
Noncontributory Pages.
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 8/15/2023
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:
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:
Approved by:
Date:
List other insurance types such as - molestation, harassment, etc.
Laurie McGinley
9/25/2023
Ak4C Rom`° CER i T;CATE i"F LIAB Li i ii INSURANCE"
09/07/2023
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy los) must have ADDITIONAL INSURED p ovisions 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(a).
PRODUCER
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne IN 46804
CONTACT NAME:
1-800 426 2889 (rA/C No); 1-260-459-5105
info@sportsinsurance-kk.com
CUSTOMER ID:
INSURERS AFFORDING COVERAGE
NAIC it
INSURED 2001529624 CP# 9348
COACHELLA VALLEY GRAND PRIX TENNIS LLC
DBA: COACHELLA VALLEY GRAND PRIX TENNIS
48375 Bighorn Dr
La Quinta, CA 92253
A Member of the Sports, Leisure & Entertainment RPG
_
INSURER A. Nationwide Mutual Insuranos Company
23787
INSURER B:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
2000592002 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
W1rD
POLICY NUMBER
POLICY EFF
DD
POLICY E XP
�Ir1M/DD
LIMBS
_
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
X
613RPGOODDO0778SOM
01/06/23
12:01 AM
01/()6/24
12:01 AM
EACH OCCURRENCE
$1,000,ODO
DA F TO RENTED$1,000,000
PREMISES Ea Occurrence
MED EXP (Any one person)
$5,000
PERSONAL & ADV INJURY
$1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$5,000,000
POLICY ❑ PROJECT II LOC
PRODUCTS— COMP/OPAGG
$1,000,000
OTHER:
PROFESSIONAL LIABILITY
$1,000,000
LEGAL LIAB TO PARTICIPANTS
$1,000,000
A
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
6BRPG0000007788000
01/06/23
12,01 AM
01/06/24
12:01 AM
COMBINED SINGLE1 (Ea
acclden
$1,000,000
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
X
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
PROPERTY DAMAGE
Per accldent
Not provided while in Hawaii
UMBRELLA
LIAR —1 OCCUR
EACH OCCURRENCE
EXCESS LIAB CLAIMS -MADE
AGGREGATE
DEDf—I RETENTION
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
NIA
PER STATUTE OTHER
ANY PROPRIETORMARTNER/ Y / N
EXECUTIVE OFFICER/MEMBER f�
EXCLUDED? (MardstorV In NH) u
It yes deft under
DESCRIPTION OF OPERATIONS belDw
E.L. EACH ACCIDENT
E.L. DISEASE —EA EMPLOYEE
E.L. DISEASE— POLICY LIMIT
A
MEDICAL PAYMENTS FOR PARTICIPANTS
6BRPG0000007786000
01/06/23
12:01 AM
01/06/24
12:01 AM
�PRIMARYMEDICAL
EXCESS MEDICAL
-
$25,000
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Addltlonal Raneaft SahodUla, mey be atfaatW N nrole @pow la requNIFj
Legal Liability to Participants (LLP) limit is a per occurrence limit.
Sport(s): Tennis Age(s): Over 19; Pickleball Age(s): Over 19
The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured.
Primary coverage provided via form SRPG8018.
Sexual Abuse Liability - $1,000,000 aggregate (included above)/ $250,000 Each Occurrence (included above)
This certificate me laces certificate #U00044483 effective 8/17123
^r wlr
y�rr r.r {VMi G r�Wl .rl CAIYCELLA 1 ium
The City of La Quinta
78-495 Calla Tampico
La Quinta, CA 92253
Owner/Manager/Lessor of Premises
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
01
U
Coverage is only extended to U.S. events and activities.
NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 6BRPG0000007788000
COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
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 Persons Or Organization(s)
The City of La Quinta
78-495 Calle Tampico
La Quinta, CA 92253
Named Insured: COACHELLA VALLEY GRAND PRIX TENNIS LLC
DBA: COACHELLA VALLEY GRAND PRIX TENNIS
CP# 9348
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.
CG 20 26 0413 0 Insurance Services Office, Inc., 2012 Page 2 of 2
POLICY NUMBER: 6BRPG0000007788000 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY INSURANCE - ADDITIONAL INSURED
This endorsement modifies insurance under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added:
Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the
additional insured named below, however this insurance does not apply to the sole negligence of such additional insured.
Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply.
Additional Insured: The City of La Quinta
78-495 Calle Tampico
La Quinta, CA 92253
Named Insured: COACHELLA VALLEY GRAND PRIX TENNIS LLC
DBA: COACHELLA VALLEY GRAND PRIX TENNIS
CP#9348
Effective Date: 8/17/23- 1/06/24
SRPG8018 09/08
POLICY NUMBER: 6BRPG0000007788000
INTERLINE
IL 12 01 1185
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000007788000
8/17/23
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
COACHELLA VALLEY GRAND PRIX TENNIS LLC
K&K Insurance Group, Inc.
DBA: COACHELLA VALLEY GRAN❑ PRIX TENNIS
COVERAGE PARTS AFFECTED
COMMERCIAL GENERAL LIABILITY COVERAGE
CHANGES
For SRPG8018 is added to the policy
CP#9348
- 44%yu _
Authorized Representative Signature
IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc., 1983
Declaration of Sole Proprietor
DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO
Coachella Valley Grand Prix Tennis LLC DBA Desert Pickleball League
Individual or Organization Name
I declare for the purpose of inducing the City of La Quinta to go forward with any contracts
awarded to Coachella Valley Grand Prix Tennis LLC DBA Desert Pickleball League as follows:
I am the authorized representative of Coachella Valley Grand Prix Tennis LLC DBA Desert Pickleball League
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
Coachella Valley Grand Prix Tennis LLC DBA Desert Pickleball League 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
Coachella Valley Grand Prix Tennis LLC DBA Desert Pickleball League
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
8/14/2023
Date
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
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
(initial) 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 ear.
(initial) California Labor Code § 3710.1 provides Lhat where an employer fails to provide
c pensation 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
suc top orders.
(initial) 1 acknowledge that if evidence is found that contradicts this declaration, City of La Quinta
wii promptly notify all relevant state agencies to ensure full insurance compliance required by Workers'
eCo ensa"on Laws of California.
initial) I understand that California Labor Code § 3700 et seq. requires employers to provide
wo kers' 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
ins once because it has no employees.
(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 C lifornia regarding workers' compensation insurance.
(initial) If I hire employees in the future, I will immediately notify City of La Quinta and provide a
er lfied 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 >1 day of 20at 401 war California
gnature of Declarant
&;�7 sc�&Ocz,
Print Name of Declarant
Print Name of Company -