Insurance Certificates 2025/26 Cuevas, JohnINSURANCE REVIEW
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CALIFORNIA -
RE: John Cuevas - Art Purchase Agreement; SilverRock Park Facility mural.
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
10/13/2025
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:
1-1$1,000,000 per occurrence/loss
Other:
Approved by:
List other insurance types such as - molestation, harassment, etc.
Oscar Mojica
Date: 10/15/2025
'a16. o CERTIFICATE OF LIABILITY INSURANCE DAT10/13/2025YY)
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 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: Veracity Insurance Solutions, LLC
PHONE (A/C, No, Ext): (844) 520-6991
Veracity Insurance Solutions, LLC.
FAX (A/C, No):
Pleasant Grove, UT, 84062
E-MAIL ADDRESS: info@actinsurance.com
INSURED
INSURER(S) AFFORDING COVERAGE NAIC #
John Cuevas
INSURER A: Great American Alliance Insurance Company 26832
77535 California Dr
Palm Desert, CA, 92211
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
ABOVE FOR THE PO 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
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
POLICY EXP
LIMITS
LTR
INSR
WVR
(MM/DD/YYYY)
(MM/DD/YYYY)
EACH OCCURRENCE $1,000,000
GENERAL LIABILITY
DAMAGERENTED $300,000
✓ COMMERCIAL GENERAL LIABILITY
PREMISES S (
(Ea occurrence)
CLAIMS -MADE ❑✓ OCCUR
MED EXP (Any one person) $5,000
A
PROFESSIONAL LIABILITY
✓❑
❑
PLF197543-AA364306
05/21/2025
05/21/2026
PERSONAL & ADV INJURY $1,000,000
(CLAIMS -MADE FORM)
GENERAL AGGREGATE $2,000,000
GENL AGGREGATE LIMIT APPLIES PER
PRODUCTS COMP/OP AGG $2,000,000
✓❑ POLICY ❑ PROJECT ❑ LOC
AUTOMOBILE LIABILITY
ANY AUTO
❑
❑
ALL OWNED AUTOS ❑ SCHEDULED AUTOS
HIRED AUTOS ❑ NON -OWNED AUTOS
EACH OCCURRENCE 0
UMBRELLA LIAB ❑ OCCUR
AGGREGATE 0
EXCESS LIAB ❑ CLAIMS -MADE
❑
❑
$
DED ❑ RETENTION $
❑ WC STATUTORY LIMITS OTHER $
WORKERS COMPENSATION AND
E.L. EACH ACCIDENT $
EMPLOYERS' LIABILITY
E.L. DISEASE EA EMPLOYEE $
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICE/MEMBER EXCLUDED
N/A
❑
E.L. DISEASE POLICY LIMIT $
(Mandatory in NH) ❑
If yes describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space required)
It is understood and agreed that the Certificate Holder is named as Additional Insured per attached CG 20 26 (Ed. 04 13) - Additional Insured - Designated Person or
Organization subject to all policy terms, conditions, and exclusions.
CERTIFICATE HOLDER CANCELLATION
The City of La Quinta and it's officers, officials, employees, agents and volunteers
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
78495 Calle Tampico
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE
La Quinta, CA, 92253
WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
41
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
INS025 (201401) The ACORD name and logo are registered marks of ACORD
GEICO
Important Information
Here are your Policy Identification Cards
We've provided two (2) cards for each vehicle on your policy.
Need additional ID cards?
The GEICO Mobile app is the quickest way to get additional ID cards. You can also send a copy of
your ID cards to anyone that needs them right from the app!
Evidence of Insurance
Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle
insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to
register or renew the registration of your vehicle. A law enforcement officer can ask you to prove
that you have liability insurance meeting the basic requirements of California law. A violation of these
requirements can result in a fine of up to: $1,000 for the first time; $2,000 for additional times. Also, a
judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and
30 days in prison.
Cut Along the Dotted Line
California Evidence of Liability Insurance
GEICOGEICO General Insurance Company
PO BOX 9506 Fredericksburg, VA 22403-9506
NAIL Code 2015 HONDA CR-V
35882 Vehicle ID No.2HKRM3H37FH560038
Policy Number Effective Date Expiration Date
4517-77-97-59 05/09/25 11 /09/25
Named Insured(s) Address
John Manuel Cuevas 77535 California Dr
Sandy Esmeralda Garciacuevas Palm Desert CA 92211-8012
I
FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE
2015 HONDA CR-V
Additional Drivers
JOHN M CUEVAS AND SANDY E
GARCIACUEVAS
77535 CALIFORNIA DR
PALM DESERT CA 92211-8012
Cut Along the Dotted Line
California Evidence of Liability Insurance
GEICOGEICO General Insurance Company
PO BOX 9506 Fredericksburg, VA 22403-9506
NAIL Code 2015 HONDA CR-V
35882 Vehicle ID No.2HKRM3H37FH560038
Policy Number Effective Date Expiration Date
4517-77-97-59 05/09/25 11 /09/25
Named Insured(s) Address
John Manuel Cuevas 77535 California Dr
Sandy Esmeralda Garciacuevas Palm Desert CA 92211-8012
I
'FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE'
2015 HONDA CR-V
Additional Drivers
This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code.
This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code.
GEICO
Need another form of proof of insurance?
You may need the Insurance Binder for most finance companies, dealerships or vehicle
registrations.
Scan this code to get another form of proof of insurance immediately!
If your address changes, update it using the app or log in to geico.com. By keeping your
information up-to-date, you'll continue to receive important policy documents.
Cut Along the Dotted Line
2015 HONDA CR-V GEICO
x Evidence of financial responsibility shall at all times be
carried in the vehicle.
x Insurance information has already been submitted directly
to the DMV electronically, submit this document to DMV
only if specifically requested by DMV.
'FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE'
If you're in an accident:
x Stay at the scene and find a safe area.
x Do not admit fault or disclose your coverage limits.
x Call the police, and gather driver and vehicle
information.
x Find any witnesses and get their contact information.
To report a claim
Go to geico.com/claims, use the GEICO Mobile app or call
1-800-841-3000.
Cut Along the Dotted Line
2015 HONDA CR-V GEICO
x Evidence of financial responsibility shall at all times be
carried in the vehicle.
x Insurance information has already been submitted directly
to the DMV electronically, submit this document to DMV
only if specifically requested by DMV.
FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE FOLD HERE'
If you're in an accident:
x Stay at the scene and find a safe area.
x Do not admit fault or disclose your coverage limits.
x Call the police, and gather driver and vehicle
information.
x Find any witnesses and get their contact information.
To report a claim
Go to geico.com/claims, use the GEICO Mobile app or call
1-800-841-3000.
U4CA (08-24) U4CA (08-24)
PLF197543-AA364306
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):
The City of La Quinta and it's officers, officials, employees, agents and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
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 shall not increase the applicable Limits of Insurance shown in the Declarations.
Copyright, ISO Properties, Inc., 2012
CG 20 26 (Ed. 04/13) PRO (Page 1 of 1)
CG 20 01 (Ed. 04 13)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARYAND NONCONTRIBUTORY- OTHER INSURANCE CONDITION
This endorsement modifies insurance provided underthe following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other Insurance
Condition and supersedes any provision to the
contrary:
Primary and Noncontributory Insurance
This insurance is primary to and will not
seek contribution from any other insurance
avail- able to an additional insured under
your policy provided that:
CG 20 01 (Ed. 04/13)
(1) the Additional Insured is a Named Insured
under such other insurance; and
(2) you have agreed in writing in a contract or
agreement that this insurance would be
primary and would not seek contribution
from any other insurance available to the
Additional Insured.
Copyright, ISO Properties, Inc., 2012
DASHBOARD > POLICIES > PLF197543-AA364306 > PRIMARY, NONCONTRIBUTORY
Primary, noncontributory
BBI Primary and Noncontributory - Other Insurance Condition CG 20 01 (Ed. 04 13)
Status Approved, paid
Additional insured The City of La Quinta and it's officers, officials, employees,
agents and volunteers
Requested on 10/14/2025
Approved on 10/14/2025
Cost $20.00
Description of operations General Liability Additional Insured General Liability Primary
(optional) and Non-contributory
Item description Primary, Noncontributory
Declaration Reeardine 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.
(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
or 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 14th day of October 2025 at Palm Desert , California
Signature of Declarant
John Cuevas
Print Name of Declarant
John Cuevas
Print Name of Company
Declaration of Sole Proprietor
DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO
John Cuevas
Individual or Organization Name
I declare for the purpose of inducing the City of La Quinta to go forward with any contracts
awarded to John Cuevas as follows:
I am the authorized representative of J o h n Cu evas
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
John Cuevas . 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
John Cuevas
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
John Cuevas
10/14/2025
Date
John Cuevas
Authorized Representative