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Insurance Certificates 2025/26 Miller, Berna - Sole ProprietorINSURANCE REVIEW Cv �Cv CALIFORNIA - RE: Berna Miller, Insurance Certificate of Liability, Additional Insured & Primary and Noncontributory Endorsement pages; Decloration of Sole Proprietor and Decloration of Workman's Comp forms. 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 5/13/2025 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: 6/2/2025 ACC CERTIFICATE OF LIABILITY INSURANCE DA5/13/2 DDIYYYY) �e.r'' Ol13/2025 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: Next First Insurance Agency, Inc_ PHONE (855)222-5919 FAX PO Box 60787 (A'S'No, EAtlt (A1C, Nog Palo Alto, CA94306 E-MAIL ADDRESS support@nextinsuran(e.com INSURERIS) AFFORDING COVERAGE NAIC N INSURER A: State National Insurance Company, Inc. 12831 INSURED IN_SURER_8: Berna Miller Berna Miller 78275 Blue Sky Way Apt C La Quinta, CA 92253 INSURER D : INSURER E Cr)VFRAC;FS CFRTIFIL'ATF IUI[MRFR-000009621 RFVISln?J NIIMRFR- 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. INSRJ TYPE OF INSURANCE ADD SU R I MMIDOIYYYY MMIDDIYYYY T POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $2,000,000.00 CLAIMS -MADE X OCCUR 'AMA f NTEO PREMISES Eaoaunence 5100,000.00 MED EXP (Any one person) S15,000.00 PERSONAL BAOVINJURY 52,000,000.00 A H X NXTFHD33DF-00-GL 04/23/2025 04/23/2026 GEN'LAGGREGATE LIMIT APPLIES PER : GENERAL AGGREGATE S4,000,000.00 POLICY !I PRO- L JECT ] LOC PRODUCTS - COMPIOPAGG 54,000,000.00 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a a dent S ANY AUTO BODILY INJURY (Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS NOWOWNED BODILY INJURY (Per accident) PROPERTY DAMAGE S � AUTOS ONLY AUTOS ONLY Pef acadenHIRED I - /Is_ li LIMBRELLALIAB I I OCCUR LEAtH OCCURRENCE 1 5 IEXCESS LIAR I CLAIMS -MADE I AGGREGATE Is I I I- DEC RETENTIONS S WORKERS COMPENSATION I I P7ARTUTE I AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERrEXECUTIVE ! 1 5 FOR I E.L-EACH ACCIDENT S OFFICERiMEMBEREXCLUDED9 NIA (Mandatory NH ( ry � in ) E.L. DISEASE - EA EMPLOYEE S If yes, descnbe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT I S Each Occurrence: S2,0D0,000.00 A Professional Liability NXTFHD33DF-00-GL 04/23r2025 04/23/2026 Aggregate: �$4,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, moybeallached 4 more space is required) The Certificate Holder is The City of La Quinta This Certificate Holder is an Additional Insured on the General Liability policy per the Additional nsured Automatic Status Endorsement. All Certificate Holder privileges apply only if required by written agreement between the Certificate Holder and the Insured, and are subject to policy terms and conditions. CFRTIFICATIP 41AI nPR r`AAIr:FI I ATInPJ The City of La Quinta LIVE CERTIFICATE 78495 Cale Tampico Rd a ' xr f �' 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LdQuln[a,CA92253 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 1 AUTHORIZED REPRESENTATIVE A NORM Click or scan to view © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NXTFHD33DF-00-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 The City of La Quinta its officers, agents, and employees 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. 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 However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 04 13 © 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 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. Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 20 10 04 13 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: Certificate Holder 78495 Calle Tampico 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 additiona 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. 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 _—PECLARATIO I declare for the -pose of ind awarded to Declaration of Sole Proprietor ND ADDENDUM TO ALL CONTRACTS AWARDED TO ividual or Organization Name the City of La Quinta to go forward with any contracts 16as follows: I am the authorized representative of &mil.. 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 ers for n;Au ired for any bid or contract awarded to All worked required will be performe 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 again City of to relating 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. these decla�ations shall constitute an addendum to any bid or contracts awarded to o s- rg ao 5— Date Auth - •ized 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 W&iinitial) 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 jooJ,ne,yy�e�ar. �"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. 9&wtiai) 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. Ac6initial) 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. $itial) 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 Ir day of 201 at ,California Signature of Declarant 8c'eA'K n E ut/, Print Name of Declarant Print Name of Company