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Insurance Certificates 2017/18 Caha, BeckyAC DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/30/2018 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: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA f PHONE 888 202-3007 FAX 520 Madison Avenue *E► AI"°rl ( ) IA/C. No): 32nd Floor ADDRESS, contact[hiscox.com New York, NY 10022 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B REBECCA CAHA INSURER C : 9812 Continental HUNTINGTON BEACH, CA 92646 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 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 ADDL SUBR POLICY EFF I POLICY EXP j LTR TYPE OF INSURANCE IN.S➢ Wy PO_ LICY NUMBER IMM>,rr11V_ YYYI l fmwoorywn f LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E.00CUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JE LOC OTHER: AUTOMOBILE LIABILITY ` I ANY AUTO ALL OWNED SCHEDULED T_ AUTOS AUTOS NON -OWNED HIRED AUTOS F AUTOS UMBRELLA LIAB _ OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRI ETOR/PARTNER/EXECUTIV E OFFICER/MEMBEREXCLUDED? ❑ N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Professional Liability N I EACH OCCURRENCE $ DAMAGE TO RENTED jPRE MISEStEaozcurrlancel $ I MED EXP (Any one person) $ PERSONAL & ADV INJURY S GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ COMBINED SINGLE LINNT $ f Es accidenll BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ fear accldam) $ EACH OCCURRENCE $ AGGREGATE S I PER OT I I ERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LIMIT S UDC-1314750-EO-17 12/10/2017 12/10/2018 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION La Quinta Housing Authority SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 78495 Calle Tampico THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN La Quinta CA +336 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �Ai- iQ I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD �0 DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/30/2018 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: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA �p.NNo.xFAX (888)202-3007LAIC. Nol: 520 Madison Avenue E-MAIL ADDRESS; contact@hiscox.com 32nd Floor New York, NY 10022 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Hiscox Insurance Company Inc 10200 INSURED INSURERS: REBECCA CAHA INSURER C 9812 Continental HUNTINGTON BEACH, CA 92646 INSURER D INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 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 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 ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICYNUMBER IMMIDD/YYYY) (MM/DDIYYYYII TYPE OF INSURANCE LIMITS X COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE Fx7 OCCUR A " GGEEN'L AGGREGATE LIMIT APPLIES PER: POLICY aT LOC OTHER_ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED I SCHEDULED AUTOS AUTOS " NON -OWNED HIRED AUTOS __, AUTOS UMBRELLA LIAB I OCCUR EXCESS LIAB I I CLAIMS -MADE N Y UDC-1314750-CGL-17 DED . RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE I'— OFFICER/MEMBEREXCLUDED? NIA r (Mandatoryin NH) If yes, describe under ,DESCRIPTION OF OPERATIONS below EACH OCCURRENCE $ 1,000,000 DAMAv w ncnl=J (Ea occurre PREMISES nce) $ 100,000 MED EXP Any one person) $ 5,000 12/10/2017 12/10/2018 1 PERSONAL & ADV INJURY S 1,000.000 GENERAL AGGREGATE s 2,000,000 PRODUCTS - COMP/OP AGG $ S/T Gen. Agg COMBINF0 SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P1tuNt±kl, uAMAGE S (Per acddr nn EACH OCCURRENCE $ AGGREGATE $ $ PER STATUTE EORH E L EACH ACCIDENT $ E L DISEASE- EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION La Quinta Housing Authority SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 78495 Calle Tampico THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN La Quinta CA +336 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '¢ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD �Ih HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC-1314750-CGL-17 REBECCA CAHA 17 August 7, 2018 Hiscox Insurance Company Inc. 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, a public body corporate and politic 78-495 Calle Tampico La Quinta,CA 92247 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zations) 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 omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 40 H I J COX Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC-1314750-CGL-17 REBECCA CAHA 18 August 7, 2018 Hiscox Insurance Company Inc. 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) City of La Quinta/La Quinta Housing Authority, a public body corporate and politic 78495 Calle Tampico La Quinta,CA 92253 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(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 omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 40 HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC-1314750-CGL-17 REBECCA CAHA 22 August 01, 2018 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART A. 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 available to an additional insured under your policy, pro- vided: you have agreed in a written contract or agreement to add such additional insured to a policy providing the type of coverage af- forded by this policy; and you have agreed in a written contract or agreement with such additional insured that this insurance would be primary and would not seek contribution from any other insur- ance available to the additional insured. CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1 Insurance Services Office, Inc., with its permission Declaration of Sole Proprietor OF 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 -W (t f .all.A as follows: I am the authorized representative of 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 memberN for. work required for any bid or contract awarded to (%(�, TA A, . All worked required will be erformed sonall and solely b me other board members of the organization, their parents, P P Y Y Y � g p > 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 coo es -a, mw-tRm--by fimmciai merest, 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 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 -20 IS Date AuthorizeRepresentative