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Insurance Certificates 2024/25 Brauckmann, Alexandra - Sole ProprietorINSURANCE REVIEWCu �CU ( AI11:0PNI!- RE: Susan Alexandra Brauckmann, Insurance for Instructor Agreement (FY 24-25) Nidra Meditation & Sound classes 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 8/1/2024 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: List other insurance types such as - molestation, harassment, etc. Oscar Mojica Date: 8/19/2024 SUSABRA-05 KABDUL ,4coR0 CERTIFICATE OF LIABILITY INSURANCE DAT811/2 DIYYYY) 8/1 /2024 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: PHONE FAX (A/C, No, Ext): (855) 827-9642 (A/C, No): (703) 563-1510 Alliant Insurance Services, Inc. 4530 Walney Rd Ste 200 Chantilly, VA 20151-2285 ADDRESS: Yoga-questions@alliant.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Lloyd's Syndicate 609 (Atrium Underwriters Limited) 00000 INSURED INSURER B: INSURER C: X Susan Alexandra Brauckmann INSURER D: 7/1/2024 50991 Washington Street Box 227 La Quinta, CA 92253 INSURER E DAMAGE TO RENTED PREMISES Ea occurrence INSURER F: MED EXP (Any oneperson) 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM DD YYY POLICY EXP MM DD YYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 X CLAIMS -MADE OCCURYOGAI966553-1 X 7/1/2024 7/1/2025 DAMAGE TO RENTED PREMISES Ea occurrence 100,000 $ MED EXP (Any oneperson) $ 2'500 PERSONAL & ADV INJURY $ Included AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 GEN'L X POLICYEl PECOT- 1:1LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ HIRED L NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Professional Liab X YOGAI966553-1 7/1/2024 7/1/2025 Each Claim 1,000,000 A Professional Liab X YOGAI966553-1 7/1/2024 7/1/2025 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THIS CERTIFICATE OF INSURANCE SERVES AS EVIDENCE OF COMBINED PROFESSIONAL/GENERAL LIABILITY COVERAGE. FURTHER, THE CERTIFICATE HOLDER IS ADDED AS ADDITIONAL INSURED PER ATTACHED ENDORSEMENT. Aggregate Limit of Liability for all coverages set forth above: $2,000,000 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of La Quinta Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 78-495 Calle Tampico La Quinta, CA 92253 AUTHORIZED REPRESENTATIVE V~r'Y- _ ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED ENDORSEMENT (with primary and non-contributory wording) Specified Member: Susan Alexandra Brauckmann Policy Number: YOGAI966553-1 Endorsement Effective Date: 07/31/2024 It is hereby agreed and understood that for the additional premium charged the person(s) or entity(ies) listed below is/are included as Additional Insured(s) under the combined Professional/General Liability policy number referenced above, but only with respect to claims or damages arising solely out of professional services rendered by the Specified Member: City of La Quinta, its officers, agents, and employees 78-495 Calle Tampico La Quinta, CA 92253 The coverage provided here under to the above-named Additional Insured shall be primary and non- contributory to any insurance or self-insurance maintained by the Additional Insured. Additional Premium: $25.00 + 2.25% (surplus lines tax) + 0.0225% (state fee) ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. Date: 8/1/2024 BY: Authorized Representative Alliant Insurance Services, Inc. Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Individual or • I declare for the purpose of ' dducin"g" the City of La Quinta to go forward with any contracts awarded to q HS&1i Q1{xiv. .0A. `I as follows: I am the authorized representative of _,31 san a&xazd`a..2 wYm1ai n 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 -s' an 01awl4trL e't"ifn . 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 Qpinta re.Jpting 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. that these declarations shall co titute an addendum to any bid or contracts awarded to ko. rwt an § - ;4 - - vsd"Ypaz-?�o 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 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 526(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. 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 ftl/ day of_0-!m 204at _ L / California WiLorl z1v w1f.14, Uld Print Name of Declarant / Print Name of Company