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Insurance Certificates 2024/25 Williams, Billie - Sole ProprietorINSURANCE REVIEW c4a 0"&a CALIFORNIA RE: Billee Williams updated Certificate of Liability, Additional Insured, Primary & Noncontributory Endorsement, and W/C. 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 6/28/24 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 P✓ 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: L List other insurance types such as - molestation, harassment, etc. Oscar Mojica 8/19/2024 A4CoRo CERTIFICATE OF LIABILITY INSURANCE DATE (M06/288/2024/2024YYY) 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(les) 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 Maguire Insurance Agency, Inc. FWI 1 Bala Plz Ste 100 Bala Cynwyd, PA 19004-1401 610.617.7900 NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL POLICY NUMBER ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # LIMITS INSURER A: Philadelphia Indemnity Insurance Company I 18058 X COMMERCIAL GENERAL LIABILITY INSURED INSURER B: Billee Williams 53110 Avenida Rubio INSURER C: INSURER D: La Quinta, CA 92253 INSURER E: CLAIMS-MADEX❑ OCCUR INSURER F: COVERAGES CERTIFICATE NUMBER: 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 THE POLICY PROVISIONS. ADDL SUBR 1 1 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X PHPK2299791-003 07/08/2024 07/08/2025 EACH OCCURRENCE $2,000,000 CLAIMS-MADEX❑ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) $2,500 X PROFESSIONAL LIABILITY PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 L AGGREGATE LIMIT APPLIES PER: POLICY F-1PROJECT F-1LOC M PRODUCTS - COMP/OP AGG $4,000,000 OTHER SAM AGGREGATE $300,000 SAM OCCURENCE $100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED AUTOSSCHEDULED AUTOS ONLY BODILY INJURY (Per accident) $ HIREONLY D AUTOS -OWNED PROPERTY DAMAGE AU OS ONLY I I (Peri accident) $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N I PER STATUTE OTHER E.L. EACH ACCIDENT $ ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) It is understood and agreed that the following entity is added as an additional insured but only with respect(s) to the operations of the named insured except that liability resulting from the additional insured's sole negligence. CERTIFICATE HOLDER CANCELLATION La Quinta Wellness Center SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE QAvenida Fonda Lauinta, CA 922253-2934 La Qu EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 1 9) 4- 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD IL N 018 0122 CALIFORNIA FRAUD STATEMENT For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. IL N 018 0122 © Insurance Services Office, Inc., 2021 Page 1 of 1 POLICY CHANGE DOCUMENT POLICY NO: CHANGE # 1 CHANGE EFFECTIVE: 07/08/2024 PH PK2299791-003 Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. FWI NAMED INSURED: Billee Williams MAILING ADDRESS 53110 Avenida Rubio La Quinta, CA 92253 - POLICY PERIOD: FROM 07/08/2024 TO 07/08/2025 at 12:01 A.M. Standard Time at your mailing address shown above. DESCRIPTION: In consideration of the premium reflected, the policy is amended as indicated below: Amended COI to Include Primary Non -Contributory Endorsement:La Quinta Wellness Center78450 Avenida La FondaLa Quinta CA 92253 Total Annual Total Prorate Additional/Return Premium $0.00 Additional/Return Premium $0.00 Total Annual Total Prorate Additional/Return Additional/Return Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 Page 1 of 1 Forms Schedule — General Liability Policy Number: PHPK2299791-003 Forms and Endorsements applying to this Coverage Part and made a part of this policy at time of issue: Form/Edition Description CG 20 26 04 13 Additional Insured - Designated Person or Organization PI -GL -005 07 12 Additional Insured Primary and Non -Contributory Insurance Page 1 of 1 POLICY NUMBER: PHPK2299791-003 COMMERCIAL GENERAL LIABILITY 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 Name Of Additional Insured Person(s) Or Organization(s): La Quinta Wellness Center 78450 Avenida La Fonda La Quinta CA 92253-2934 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 applicable Limits of Declarations. shall not increase the Insurance shown in the CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: PHPK2299791-003 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 Name of Person or Organization (Additional Insured): La Quinta Wellness Center Effective Date: 07/08/2024 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. Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO �tjap__ uu', tl L�r�� Individual or Organization Name declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to �wc �. 7'�fYvs� as follows: am the authorized representative of 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 Z7�� .d for any bid or contract awarded to y "k-- � ( L [ -. _ . 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 andlor Labor laws agCity of Lf , LaQuintaQuinta relating to any bid or contract awarded to UL� w v1, L , 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. iathese declarations shall constitute an addendum to any bid or contracts awarded to t VL94 "it LII31ag Date Authorized Representative 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 htti)://www.dir.ca,poy, 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. (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. I&O(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. 19�(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 day of 2C�qat California Signature of Declarant Print Name of Declarant Print Name of Company