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Insurance Certificates 2025/26 Erickson, Alice - Sole ProprietorINSURANCE REVIEW ,(,/ "&a CALIFORNIA - RE: Alice Erickson, Certificate of Liability, Additional Insured and Primary and Noncontributory pages, Declaration of Sole Proprietor and Declaration of Workman's Comp. 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 /12/2025 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: 1 /13/2026 ACC?R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDIYYYY) 11/12/2025 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 Michele Reitz NAME: Correll Insurance Group of Hilton Head PHONE (843) 765-7733 FAX A/C No t : (VA No : PO Box6869 E-MAIL mreitz@correllhhi.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Hilton Head Island SC 29938 INSURERA: Philadelphia Indemnity 18058 INSURED INSURERS: Professional Tennis Registry, Inc. INSURER C : Professional Pickleball Registry, Inc. INSURERD: Professional Platform Tennis Registry, Inc. 5700 Saddlebrook Way INSURER £: Wesley Chapel FL 33543 INSURERF: COVERAGES CERTIFICATE NUMBER: 2025-2026 Master REVISInN NCIMRFR: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE IN D WVD POLICY NUMBER MM16D1YCY YYY MM10D P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR PHPK2584296 09/01/2025 09/01/2026 EACH OCCURRENCE $ 1,000,000 A' TFiJ PREMISES Ea occurrence S 100,000 MED EXP (Any one person) $ Excluded PER50NAL&ADVINJURY s 1,000.000 GEN'LAGGREGATE LIMITAPPLIES PER: X PRO- ❑ POLICY ❑ JECT LOC OTHER: GENERAL AGGREGATE S 3,000,000 PRODUCTS-COMPlOPAGG 5 3,000.000 $ AUTOMOBILE LIABILTTY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBWED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Peraccidenl) $ PROPERTY DAMAGE Per accident S S A X UMBRELLA LIAS EXCESS LIAB X OCCUR CLAIMS -MADE PHUBB75223 09/01/2025 09/01/2026 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X RETENTION S 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LfABELITY YIN ANY PROPRIETORIPARTNE;RIEXECUTIVE ❑ OFFICBRIMEMBER EXCLUDED (Mandatory In NH) If yes, describe under DESCRIPTION OFOPERATIONS below NIA PER OTH- STATUTE ER EL. EACH ACCIDENT 5 E.L. DISEASE EA EMPLOYEE S E.L. DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mom space Is required) [Job #: 963 Job Type: ] 152898 - Certificate Holder is listed as Additional Insured # 963 with respect to Member # 152898 -Alice Erickson , 5005 N Tripp Ave , Chicago IL 60630 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of La Quinta ACCORDANCE WITH THE POLICY PROVISIONS. 78-495 Calle Tampico AUTHORIZED REPRESENTATIVE t`La Quinta Quinta CA 92253 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: IPHPK25842961 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURE® - DESIGNATE® 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 78-495 Calie Tampico La Quinta CA 92253 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — 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. CG 20 26 0413 © Insurance Services Office, Inc., 2012 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 Effective Date: 09/01/2025- PHPK2584296 Name of Person or Organization (Additional Insured): 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. Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO 111rt-4C,e t ICA-GZ)" Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to MACC W-kC{LS60 as follows: I am the authorized representative of &--=-1C Ge.tCICSO" 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 AI,IC, j 12(C.e-sc*j . All worked required will be perfon-ned 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 A(.j C,6 21 Gcsa.f 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 A L11 W eKI cKS00 Date Authorized 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" 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. a-4(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. AL4{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. 0-4{initial) I understand that California Labor Code § 3700 et seq. requires employers to provide workers' compensation insurance coverage for any employees of my business. l 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 for loss or liability which may arise from the failure of my business to comply with the laws of the State 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 day of- California California ei ' L,-- signature of Declarant At,« O'l, t GIe-S 4 rJ Print Name of Declarant Print Name of Company