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Insurance Certificates 2022/23 Desert Aids Project (DAP)INSURANCE REVIEW W �W FORNIA RE: Insurance Certificate of Liability with Additional Insured endorsement pages for DAP Revivals Volunteer Services 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 07-18-2023 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: List other insurance types such as - molestation, harassment, etc. Approved by: Date: L / A� " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 7/18/2023 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 (OC) Heffernan Insurance Brokers 18004 Sky Park Circle, Suite 210 Irvine CA 92614 CONTACT NAME: Heffernan Insurance Brokers PHONE FAX AIC No Ext : 925-934-8500 A/C No): 925-934-8278 ADDRESS: HIB24-7@heffins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: National Fire & Marine Insurance Company 20079 License#: 0564249 INSURED DESEAID-03 INSURER B : Travelers Property Casualty Company of America 25674 Desert Aids Project Inc 1695 N Sunrise Way INSURERC: Hiscox Insurance Company Inc. 10200 INSURERD: Houston Casualty Company 42374 Palm Springs CA 92262 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:62014680 REVISION NUMBER: 1 Added Professi 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 Y HN017770 10/5/2022 10/5/2023 EACH OCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR TED PREMISES (Ea oDAMAGE TO ccurrence) $ 250,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY ❑ PRO- JECT ❑ LOC X PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: B AUTOMOBILE LIABILITY 8107S8202122243G 10/5/2022 10/5/2023 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY A UMBRELLA LIAB X OCCUR EN017770 10/5/2022 10/5/2023 EACH OCCURRENCE $ 4,000,000 X AGGREGATE $ 4,000,000 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 $ A Prof. Liability - Claims Made HN017770 10/5/2022 10/5/2023 $1,000,000 Per Claim $3,000,000 Aggr C D Crime Cyber UC24256355.22 H22EMD50404400 10/1/2022 10/5/2022 10/1/2023 10/5/2023 Third Parties' Prop. $3,000,000 Per Claim $1,000,000 $3,000,000 Aggr DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: As Per Contract Or Agreement On File With The Insured. City of La Quinta is included as additional insured on the General Liability policy per the attached endorsement, if required. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD MedPro Group 1 _ a BAFhim Flalha y campy Issuing Company: National Fire & Marine Insurance Company Omaha, Nebraska THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULL Y, Endorsement No.: Forming Part of Policy No.: Issued to: 7 HN017770 Desert AIDS Project Inc. Effective Date of Endorsement: 10/05/2022 at 12:01 a.m. at the address of the First Named Insured stated herein. BLANKET ADDITIONAL INSURED ENDORSEMENT (GENERAL LIABILITY) Only with respect to coverage provided under this endorsement and under the General Liability Coverage Part, and in consideration of the payment of the additional premium due, if any, and in reliance upon the representations of all insureds, the company and the insureds agree to amend the policy as follows: The definition of additional insured in the Definitions section of the Common Policy Provisions and Conditions is deleted and replaced with the following: Additional insured means any person or organization with which the insured has entered into a written contract or agreement prior to the event or offense agreeing: 1. to add the person or organization as an additional insured; or 2. to hold harmless or indemnify such person or organization. However, such person or organization is not an additional insured with respect to events or offenses arising from, or in connection with, any acts or omissions alleged to have been committed by that additional insured. The following subparagraph is added to all Insuring Clauses of the General Liability Coverage Part: The company's duty to defend and pay losses or claims expense on behalf of any insured shall extend to any additional insured meeting the terms and conditions of this policy, but only with respect to any loss or claims expense payable as the result of the additional insured's vicarious liability for the acts or omissions of an insured otherwise covered under this Coverage Part. However, the coverage provided to an additional insured shall not be broader than that which an insured is required by written contract or agreement to provide to that additional insured and is subject to all other conditions, definitions, exclusions and terms applicable to the insured. Additionally, coverage shall not apply to structural alterations, new construction or demolition operations performed by or on behalf of an additional insured. The following provision is added to the Limits of Liability section of the General Liability Coverage Part: ADDITIONAL INSUREDS Additional insureds share the Limits of Liability of the insured for which the additional insured is alleged to be vicariously liable for the acts or omissions of the insured otherwise covered under this Coverage Part. All other terms and conditions of the policy remain unchanged. 1506-PGX-00-0121 Page 1 of 1 © 2021 MedPro Group. All rights reserved. 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://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. 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 year. TL (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. , ��—(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. d yt, (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. �'— (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. (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 2 ` day of AV SUS 1 20 ZTat SPAR& f , California Signature of Print Name of Declarant Print Name of Company 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 Dom' 9 A-L fl 1— as follows: I am the authorized representative of �,aA-�,,n,4- 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 PAP w..._ 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 bas 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 JL 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 fiarther 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 Date Authorized presentative