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Insurance Certificates 2024/25 Shiry, Teresa - Sole ProprietorINSURANCE REVIEWCu �CU — ( Al i ORNIA RE: Teresa Shiry, Insurance Documents for fiscal year agreement (2024- 2025) for Ballroom,Latin,Swing classes to be performed at the Wellness Center. 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 5/23/2024 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: Date: List other insurance types such as - molestation, harassment, etc. Oscar Mojica 8/27/2024 78455 Calle iamplcn I Ia pulnta, Fall I . i d I A4CoRo CERTIFICATE OF LIABILITY INSURANCE DATE (M05/233/2024/2024YYY) 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: Teresa Shiry 52390 Avenida Velasco INSURER C: INSURER D: La Quinta, CA 92253-3276 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/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X PHPK1343296-009 06/01/2024 06/01/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADEX❑ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) $2,500 X PROFESSIONAL LIABILITY PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 L AGGREGATE LIMIT APPLIES PER: POLICY F-1PROJECT F-1LOC M PRODUCTS - COMP/OP AGG $3,000,000 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 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. Division Name: Wellness Center CERTIFICATE HOLDER CANCELLATION City of La Quinta SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE QCalle Tampico Lauinta, CA 92253-2839 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 POLICY CHANGE DOCUMENT POLICY NO: CHANGE # 1 CHANGE EFFECTIVE: 06/01/2024 PHPK1343296-009 Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. FWI NAMED INSURED: Teresa Shiry MAILING ADDRESS 52390 Avenida Velasco La Quinta, CA 92253-3276 POLICY PERIOD: FROM 06/01/2024 TO 06/01/2025 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 1 Additional Insured City of La Quinta to add WOS, PNC and DOO Language 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 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): City of La Quinta Effective Date: 06/01/2024 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. POLICY NUMBER: PHPK1343296-009 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): City of La Quinta 78495 Calle Tampico La Quinta CA 92253-2839 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: PHPK1343296-009 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of La Quinta Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. ISO Properties, Inc CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ 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 Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Individual or Organization I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to as follows: I am the authorized representative of .. l 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 rqUiro for any bid or contract awarded to . All worked required will be performed personally and solely by me, othe 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 Quintaelating 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. I agree that these declarations shall constitute an addendum to any bid or contracts awarded to Date c Authorized Representative Declaration Regarding C aliforniaWorkers' C ompensation You are required to complete this form because you have not filed a certificate regarding workers' compensation insurance with C ityof 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 lttp://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' C ompensationLaws of C alibrnia, 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 C ityof 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. ACK/ OWLEDGMENT ` (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 C ode§ 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 C ode. Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to one yea znitial) C alifornia Labor Code § 3710.1 provides that where an employer fails to provide C" 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 C ode§ 3710.2 makes it a criminal offense to disregard sur,M s op orders. ial) I acknowledge that if evidence is found that contradicts this declaration, C ityof La Quinta will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' CO nsation Laws of California. �/initial) I understand that California Labor C ode§ 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 C alifornia Labor C ode provisions regarding workers' compensation insu to 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 f rnia regarding workers' compensation insurance. rtial) If I hire employees in the future, I will immediately notify C ityof La Quinta and provide a c ified Workers' C ompensationcertificate to the C ity. 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 thisday of % 20�t California Signature of Declarant Print Name of Declarant Print Name of Company