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Insurance Certificates 2025/26 Palm Springs Party Co LLCINSURANCE REVIEW Cv �Cv CALIFORNIA - RE: Palm Springs Party Company LLC Insurance Packet for the Easter Eggstravaganza and the City's 44th Birthday Celebration 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 reauired per the Agreement: ACCORD Certificate dated 10-days prior or less 01/26/2026 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: 2/9/2026 / AC"R " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 01 /26/2026 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 Laurie Baldwin NAME: AssuredPartners of Arizona, LLC PHONE FAX A/C No Ext : (A/C, No): 14614 North Kierland Boulevard, Suite #150 E-MAIL Laurie.Baldwin@assuredpartners.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Scottsdale AZ 85254 INSURERA: W.R. Berkley Corporation INSURED INSURER B : Great American Insurance Company 16691 Palm Springs Party Company, LLC INSURER C : INSURER D : 81074 Jessica Way INSURER E : Indio CA 92201 INSURER F : COVERAGES CERTIFICATE NUMBER: 25-26 Master REVISION 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 CONTRACTOR 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGE PREM SESO(Ea occurrence) $ 100,000 _7RETED MED EXP (Any one person) $ Excluded PERSONAL& ADV INJURY $ 1,000,000 A Y CGL017982323 12/07/2025 12/07/2026 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JJECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ElN D? OFFICER/MEMBER EXCLUDE / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Excess Accident B BSR-E883624-03 12/07/2025 12/06/2026 Limit Per Claim $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of La Quinta, its officers, officials, employees and agents are listed as additional insureds on a primary and non-contributiory basis on the above general liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of La Quinta, its officers, officials, employees and agents ACCORDANCE WITH THE POLICY PROVISIONS. 78495 Calle Tampico AUTHORIZED REPRESENTATIVE La Quinta CA 92253 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - YOUR AMUSEMENT OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization(s): Any party for whom you are providing ongoing operations, and the owner of the premises where the ongoing operations are being performed. 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 to the extent that the liability for "bodily injury", "property damage" or "personal and advertising injury" is caused solely by your negligent acts, errors or omissions in the performance of ongoing operations for the additional insured shown in the Schedule. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" to any employee of you or to any obligation of the additional insured to indemnify another because of damages arising out of such injury. 2. "Bodily injury", "property damage" or "personal and advertising injury" for which the Named Insured is afforded no coverage under this policy of insurance. C. With respect to the insurance afforded to these additional insureds, SECTION III — LIMITS OF INSURANCE is amended to include the following: The limits applicable to the additional insured are those specified in any agreement or in the Declarations of this Coverage Part, whichever is less. If no limits are specified in the agreement, the limits applicable to the additional insured are those specified in the Declarations of this Coverage Part. The limits of insurance are inclusive of and not in additional to the limits of insurance shown in the Declarations. D. With respect to the insurance afforded to these additional insureds, paragraph 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended to include the following: Any coverage provided herein will be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless you have agreed that this insurance will be primary. This insurance will be noncontributory only if you have so agreed and this coverage is determined to be primary. All other terms and conditions of this policy remain unchanged. BR5085G (11/19) Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Commercial General Liability Conditions: We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or "your work" done under a written contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only when you and that person or organization have agreed to such waiver in writing in a contract or agreement. All other terms and conditions of this policy remain unchanged. L609 (05/09) Includes copyrighted material of Insurance Services Office, Inc., with itspermission. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to include as an additional insured any person or organization when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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, but only for "occurrences" or coverages not otherwise excluded in the Coverage Part to which this endorsement applies. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. Status as an additional insured for the person or organization to which this endorsement applies: 1. Commences during the policy period and after such written contract or agreement has been executed; and 2. Ends when: a. Your ongoing operations for that additional insured are completed; b. The contractor's contract or agreement is terminated; or c. Your policy cancels or expires; whichever occurs first. C. With respect to the insurance afforded to the additional insured, the following additional exclusions apply: This insurance does not applyto: 1. "Bodily injury", "property damage", "personal and advertising injury" or medical payments arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering, or surveying services. L805 (10/19) Includes copyrighted material from Insurance Services Office, Inc., with its permission. Page 1 of 2 2. "Bodily injury" or "property damage" occurring after: a. 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 b. 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. D. With respect to the insurance afforded to the additional insured, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. E. The following is added to 4.a. of Other Insurance of Section IV - Commercial General Liability Conditions: If required in a written contract, the Coverage Part to which this endorsement applies is primary and noncontributory in the event of an 'occurrence" caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf that occurs while performing ongoing operations for the additional insured. All other terms and conditions remain unchanged. L805 (10/19) Includes copyrighted material from Insurance Services Office, Inc., with its permission. Page 2 of 2 CGL 0179823 - 23 12/07/25 KRM 12/11/25 POLICY NUMBER: 0179823-23 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 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): Per Schedule on File 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 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 26 12 19 Copyright, Insurance Services Office, Inc., 2018 Page 1 of 1 CGL 0179823 - 23 12/07/25 KRM 12/11/25 POLICY NUMBER: 0179823-23 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 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): Per Schedule on File 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 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 26 12 19 Copyright, Insurance Services Office, Inc., 2018 Page 1 of 1 ACOR" CERTIFICATE OF LIABILITY INSURANCE lk.� DATE (MM/DD/YYYY) 08/29/2025 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: Julie Contreras A//CNN Ext: (760)775-7256 (AC No; (760)775-7222 Palm Valley Insurance 45541 Oasis St Indio, CA 92201 E-MAIL ADDRESS: julie@palmvalleyinsurance.com y INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: infinity Select Insurance Company 20260K INSURED INSURER B : INSURERC: Palm Springs Party Company INSURER D : 81074 Jessica Way Indio, CA92201-3709 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: 00088151-250829124748 REVISION NUMBER: 1 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 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 LTR OF INSURANCE ADDLSUBRTYPE INSD WVD POLICY NUMBER EFF MM/ DPOLICY/YYYY Y EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE1:1 OCCUR EACH OCCURRENCE $ DAMAGE TO PREMISESEa occu ence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 50008160901 05/03/2025 05/03/2026 Ea accc den SINGLE LIMIT $ 1 000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of La Quinta THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 78495 Calle Tampico AUTHORIZED REPRESENTATIVE La Quinta, CA 92253 I I 69wtll�_ JCC © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are re tered marks of ACORD Printed by JCC on 08/29/2025 at 12:49PM Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Individual or Organization Name I declare for the purpose of inductE-, the City of La Quinta to go forward with any contracts awarded to QAkv. Se ri ryg (!, !^PG"i L L a. as follows: I am the authorized representative of (I r--n"ni L i- C 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 SPT�( ;., LLC 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 agar st City of La Quinta 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. that these declarations shall constitute an addendum to any bid or contracts awarded to Ar, S' P r; nai �'1 �i�j (�v.�,nn r.I L L G 9--S-zo2�- 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.Rov. 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. .2�(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 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. (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 u Usy 20 2f at h � . California Signature of Declarant 5., -&, /yL, neN., Print Name of Declarant Print Name of Company f-