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Insurance Certificates 2019/20 PAX Fitness Repairs, LLCAC"Rii CERTIFICATE OF LIABILITY INSURANCE �4. DATE(MMIDD/YYYY) 09/05/2019 V� 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 Kevin Glenn NAME: Palm Desert Insurance Agency A/ON[J (760) 341-2345 AID Nu : (760) 341-0865 73241 Highway 111 Suite 1-13 E-MAIL kevin@pal mdesertinsurance net ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC S Palm Desert CA 92260 INSURERA: Scottsdale Insurance Company INSURED INSURER B : California Automobile Insurance Co. 38342 PAX Fitness Repair, LLC INSURER 114 Romanza Ln INSURER D INSURER E Palm Desert CA 92211 INSURER F. COVERAGES CERTIFICATE NUMBER: CL197100777 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 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 INSR LTR TYPE OF INSURANCE 1NSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000,000 CLAIMS -MADE Fx_] OCCUR PREMISES Ea Occurrence S 100,000 MED EXP (Any one person) s 5,000 PERSONAL & ADV INJURY s 1,000,000 A Y CPS3172226 07/01/2019 07/01/2020 GEN'LACGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY ❑ j LOC PRODUCTS - COMP/OPAGG S 2,000.000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMFF Ea accldenl S 1,000,000 BODILY INJURY (Per person) S ANYAUTO B OWNED SCHEDULED AUTOSONLY AUTOS Ix BA040000053563 07/01/2019 07/01/2020 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accIdem S HIRED x NON -OWNED AUTOS ONLY /'� AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S HCLAIMS-MADE AGGREGATE s EXCESS LIAB DED RETENTION S $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER EL EACH ACCIDENT s ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? NIA EL DISEASE- EA EMPLOYEE S (Mandatory in NH) Ir yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City if La Quinta is named as additional insured and coverage is primary and non-contributory with respect to the general liability policy per endorsement #GLS-150s (7-06) and CG20011219 CERTIFICATE HOLDER CANCFLLATION 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. 78450 La Fonda 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 �� SCOTISDALE INSURANCE COMPANYa ENDORSEMENT NO. ATTACHED TO AND FORMING A PART OF O R ENDDSEMENT EFFECTIVE DATE NAMED INSURED AGENT NO POLICY NUMBER (1 A.M. STANDARD TIME) CPS3172226 07/01/2019 PAX FITNESS REPAIR, LLC 04068 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional in- sured any person or organization whom you are required to add as an additional insured on this policy under a written contract, written agreement or written permit which must be: a. Currently in effect or becoming effective during the term of the policy; and b. Executed prior to the "bodily injury," "property damage," or "personal and advertising injury." The insurance provided to these additional insureds is lim- ited as follows: 1. That 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: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations for that additional insured are completed. a. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion of the covered operations has been com- pleted; or b. That portion of "your work" out of which the in- jury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written contract, written agreement or written permit or in the Decla- rations for this policy, whichever is less. These lim- its of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declara- tions for this policy. 4. Coverage is not provided for "bodily injury," "property damage," or "personal and advertising injury" arising out of the sole negligence of the additional insured. 2. With respect to the insurance afforded to these 5. The insurance provided to the additional insured additional insureds, the following exclusions are does not apply to "bodily injury," "property damage," added to item 2. Exclusions of SECTION I— or "personal and advertising injury" arising out of COVERAGES: an architect's, engineer's or surveyor's rendering of or failure to render any professional services This insurance does not apply to "bodily injury," including: "property damage" or "personal and advertising injury" occurring after: Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc , 2004 GLS-150s (7-06) Page 1 of 2 a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engi- neering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance avail- able to the additional insured whether primary, ex- cess, contingent or on any other basis unless a written contract specifically requires that this insur- ance be primary.. When this insurance is excess, we will have no du- ty under SECTION I —COVERAGES to defend the additional insured against any "suit" if any other in- surer has a duty to defend the additional insured against that "suit.." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 GLS-150s (7-06) Page 2 of 2 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 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 with whom the insured has agreed to waive rights of recovery, provided such agreement is made in writing and prior to the loss I Information required to complete this Schedule, if not shown above, will be shown in the Declarations 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 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 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 LIQUOR 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 available to an additional insured under your policy provided that: (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. CG 20 01 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 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. 14"nn(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. An (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 5�P-��e►2 161at f J Lem Y�3G - f California Signat ar-�JZant Print Name of Declarant PA-x F(TWO 5 S Print Name of Company