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Insurance Certificates 2024/25 Jensen, Sharla - Sole ProprietorINSURANCE REVIEWCu �CU ( Al IFOR\IA - RE: Sharla Jensen updated Certificate of Liability Insurance, Additional Insured & Primary and Noncontributory Endorsement documents for FY 24-25. 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 8/15/2024 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: Sexual Abuse & Molestation Liability under GL Approved by: List other insurance types such as - molestation, harassment, etc. Oscar Mojica Date: 8/29/2024 ACORH CERTIFICATE OF LIABILITY INSURANCEII aUV'V2ft24""¢' THIS CERLER(M IE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRM LUVELY 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), AUTHORVEo REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: FIRE cMilcate holder is an ADDITIONAL INSURED, the irmicydes) must ham ADDITIONAL INSURED Powisions or be endorsed. N SUBROGATION 15 WAIVER, subject to the t and conditions of the policy, certain policies may require an endorsement A statement on FAR ceriffiute does Plot comer rights to the cxrtilcarte holder in lieu of such entlmsementjs). ROME NOB Pot Insurance Tgenry, OF PdoAll p9awB u.1e551u2319 xxo" ADDRESS . "Pw ne.nn.uranrernm ea 51 AFFORDING w InURERA- State Ilawnaun insurance mmW nr rc. 1M3i INSURED INSUMERB Sturlaknun Shoda kes,INSURERH IRMURERDalINSUREIREINSUREIRE t Im 0eunC"CACI �5pc L3 ®.aarse$1DOW DO NEEDIESPOSaxerenza) 15.00000 REVISION NUMBER: THEL IS TO CERTIFY THAT THE PIXICIES OF INSURANCE LISTED BELOW HAVE BEEN BORDEN TO SHE INSURED NAMED ABOVE FOR WE POLICY PERgO INDICATED NJTWIIHSTPROING ANY REQUIREMENT TERM OR CONo1IICN OF ANY WNRNGT OR OTHER DOCUMENT WITH RESPECT TO NHIGI1H15 CERPFICATE MAY BE ISSUED OR MAY PERTAIN, WE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IR EFFECT TO AL SHE TERI EXCLUMONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MY HAVE BEEN REDUCED BY PAID CLAIMS UPON WILL BE DELIVERED 1 HE SUM POLICE Err PAILIFY UP na aRum REPl Sc ATW w a2,mNMO O OUNIR ®� ®.aarse$1DOW DO NEEDIESPOSaxerenza) 15.00000 PERSONAL9,4EVULAW a1.000,00000 ra SACISla3RL 1WINEVE3 R26a024 n sa.OW,BSOO n1:1M oTo s200D000 DD.WD.DD AmOMBI re a floassal ANYAUTO ALMOONI ACT RYIPaassatl a UNBRELUMB OURS AN S STATUTHE wre o x EL EL OF OFERN �n USS,o�n Profezzlowl DINIty X%TTY.p8Q51-03GL REJON23 IQEPIMN $4000,000 DO .a MCm IS. Adertannal.. . Maybe All frawous"manal The Cenl&atr lrober IS Ory nap lnw City a to Pw ro lS an Adamonadnmrea On TO onnalLamah By on a moRR led non-ennmbrrtery bazlz Cay of La pdnra 1. n AMI rams! onth,General uniNflty polity suh remtt to mgornKcperatlonz. Gty TIaQ [a6an Mtll[imal lnzu omM1e General U%114 baCL CRY Of T rezpe¢ Ro plehd CpemEonx At CeM¢ale xdtlerpmilBezapu^Onp Rgreyulrea b�waRn agrvnnembeMeen Ue Gty Ala Qur antl,M1e lmuredbr Personallralnerforboth aaulbandmrnoR$e CISM7"95CaIle TampM,I SPUR, Z253plrizim RAm, dlne4C¢ner. kfabon zubfe¢bpollryrermz antlmndmonz CERTFlCATE HOLDER CANCELLATION orW,Q rma GO 01 SHOULD ANY' OF THE ABOVE DESCRIBED POLICIES BE CANICEITED BEFORE 28195UIk Tam I[ WILL BE DELIVERED 1 Ia alma, En 9285$ ACCORDANCE WITx THE POLICY PROVISIONS. aRum REPl Sc ATW 0INS-015 AWED CORPORATION. All Whis resmed. ACOR025(201 SUDS) T1e ACORD Bane and bpo are registered Bl Io1ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 09 POLICY NUMBER POLICY CHANGES COMPANY EFFECTIVE NXTTK88QS1-03-GL 08/15/2024 State National Insurance Company, Inc. NAMED INSURED AUTHORIZED REPRESENTATIVE Sharla Jensen Sharia Jensen 73450 Country Club Dr Spc 273 Palm Desert, CA 92260 Ann Ryan COVERAGE PARTS AFFECTED Commercial General Liability Coverage Part CHANGES SEE ATTACHED SCHEDULE Return Total $0.00 Authorized Representative Signature IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 2 13 Copyright, ISO Commercial Risk Services, Inc., 1983 SCHEDULE OF POLICY CHANGES I It is understood and agreed that: The following forms are added: NXT-0084 BM GL 0218 - Designated Additional Insured - Primary Insurance CG 20 10 04 13 - Additional Insured - Owners, Lessees or Contractors - Scheduled Person or Organizat on CG 20 37 04 13 - Additional Insured - Owners, Lessees or Contractors - Completed Operations other terms and conditions remain unchanged. IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 ❑ Copyright, ISO Commercial Risk Services, Inc., 1983 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED - PRIMARY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person or Organization: City of La Quinta 78495 Calle Tamp co La Quinta, CA 92253 SECTION II - WHO IS AN INSURED is amended to include the person or organization 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. II. 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. III. Coverage provided to the additional insured shown in the SCHEDULE is afforded on i) a primary basis, ii) a noncontributory basis, or iii) a primary and noncontributory basis in accordance with the applicable written contract between you and the additional insured. All other terms and conditions of the policy remain unchanged. NXT-0084 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 1 permission POLICY NUMBER: NXTTK88QSi-03-GL COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED 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) Locations Of Covered Operations City of La Quinta CA 78495 Calle Tampico La Quinta, CA 92253 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 2010 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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 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. Page 2 of 2 O Insurance Services Office, Inc., 2012 CG 20 10 0413 POLICY NUMBER: NXTTK88Q51-03-GL COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL_ LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 Personal Trainer services n CA Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section It — 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". 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 37 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 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.-, h lk4 �''} �lS P�!/ 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 required for any bid or contract awarded to '3\-, '7\ 2 t, A- '3 -1r, %"k SQ —. 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 S k.H- t -i -d ,-T� 11 S c -G111 _ - 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 cons itute an addendum to any bid or contracts awarded to S �mac..L4 .� PM S �oY 0 Date Authorized Represea 06ve 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. eV(initial) California Labor Code § 3710.1 provides that where an employer fails to provide 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 such stop orders. (initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta wiN,promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' Compensation Laws of California. nitial) I understand that California Labor Code § 3700 et seq. requires employers to provide wor ers' 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 ecause 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 =temployees g workers' compensation insurance. 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 mourn -Le- 20,1�1at L.0 I1,% ' , California Signature of DeclEjoint ShItk-4 0 Print Name of Declarant oil kA k4 Print Name of Company