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Insurance Certificates 2025/26 Jensen, Sharla - Sole ProprietorINSURANCE REVIEW RE: Sharla Jensen, Personal Trainer updated Certificate of Insurance, Additional & Primary and Noncontributory Endorsement pages. 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 11/14/25 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: Sexual Abuse & Molestation covered by GL List other insurance types such as - molestation, harassment, etc. Approved by: Date: [fTEJ(MWDDIYYYY) ®CERTIFICATE OF LIABILITY INSURANCE 4/2025 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 erldorsement(s). PRODUCER CONTACT _NAME: Next First Insurance Agency, Inc. PHONE (855) 222 5919 FAX PO Box 60787-9AtC'-N° WC, NoK_ Palo Alto, CA 94306 ADDRESS: support@nextinsurance.com INSII RFRlS1 AFFORDING COVERAGE NAILS INSURED Sharla Jensen Shara Jensen 73450 Country Club Dr Spc 273 Palm Desert, CA 92260 INSURER A: INSURER B: State National Insurance Company, Inc. P n%1CDAr^_CC r PDTIFICATF NI1RARr-P- AR3n3913R RF'VIS ION 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 TYPE OF INSURANCE ADDL SVBR POLICY NUMBER POLICY EFF YYYI MWD Y EXPLTR LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $2,000.000.00 CLAIMS -MADE X OCCUR PREMISESO R occurrence $100.000.00 MED EXP (My one person) $15,000.00 PERSONAL 8 ADV INJURY $2,000,000.00 A X NXTTK88QS1-05-GL 10/26/2025 10/26/2026 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000.00 PRODUCTS - COMPIOP AGG S4,000,000.00 X POLICY ❑ JPERCT n LOC $ OTHER: AUTOMOBILE LIABILITY COMBINEDSINGLELIMII Ea .cadent $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOSONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per acadenQ S PROPERTYDAMAGE Per accldentl $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTIONS $ WORKERSCOMPENSATIDN AND EMPLOYERS' LIABILITY YIN N ANYPROPRIETORlPARTNERIEX£CUTIVE PER OTH- STATUTE ER EL. EACH ACCIDENT s OFFICE RIM EMBER EXCLUDED? El (Mandatory in NH) NIA EL. DISEASE -EAEMPLOYEE $ EL.DISEASE -POLICY LIMIT S If yyes describe under DESCRIPTIONOFOPERATIONS I)ebw I Each Occurrence: $2,000,000.00 A Professional Liability NXTTKBBQSI-05-GL 10/26/2025 10/26/2026 Aggregate: $4,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tat, Addilkwal Remarks Schedule, may be attached if more space is required) The Certificate Holder is City of La Quinta. This Certificate Holder is an Additional Insured on the General Liability policy per the Additional Insured Automatic Status Endorsement. All Additional insured privileges apply only if required by written agreement between the Certificate Holder and the insured, and are subject to policy terms and conditions. rCorlrrr-Ar= unI ncD C AW'1=1 I ATIr1IU City of La Quinta LIVE CERTIFICATE 78-495 Calle Tampico y a La Quint., CA 92253 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Click or scan to view AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORA I ION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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 78-495 Calle Tampico La Quinta, CA 92253 I. 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. It. 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: NXTTK88Qs1-05-GL COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization against whom you have agreed to waive such right of recovery in a written contract or agreement I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. j 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 against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 I SCHEDULE OF POLICY CHANGES It is understood and agreed that: The followingg forms are added: NXT-0084 BNl GL 0218 - Designated Additional Insured -Primary Insurance other terms and conditions remain unchanged. IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 O Copyright, ISO Commercial Risk Services, Inc., 1983 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 3ti'7\ 2 t, A- ' J -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� 11S 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 3 �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. (initial) California Labor Code § 3710.1 provides that where an employer fails to provide eVpensation 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 g workers' compensation insurance.=temployees 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