Loading...
Insurance Certificates 2019/20 FIND Food BankSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 7/9/2020 Arthur J.Gallagher Risk Management Services,Inc. 2850 Golf Road Rolling Meadows IL 60008 Jeremiah Polk 630-773-3800 630-285-4062 Philadelphia Indemnity Insurance Company 18058 FOODINN-01 Carolina Casualty Insurance Company 10510FoodInNeedofDistribution,Inc. 83-775 Citrus Avenue Indio CA 92202 Service American Indemnity Company 1599540290 A X 1,000,000 X 100,000 5,000 1,000,000 3,000,000 X PHPK2074042 12/15/2019 12/15/2020 3,000,000 A 1,000,000 X PHPK2074042 12/15/2019 12/15/2020 A X X 3,000,000PHUB70422912/15/2019 X 12/15/2020 3,000,000 10,000 C XSATIS00225007/1/2020 7/1/2021 1,000,000 1,000,000 1,000,000 B Directors &Officers DCP-1795595-P1 12/15/2019 12/15/2020 LIMIT $1,000,000 City of La Quinta,CA and all of its officers,employees,agents,and volunteers is listed as additional insured with respect to General Liability coverage. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 USA WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 7-01) c POLICY INFORMATION PAGE ENDORSEMENT The following item(s) Insured's Name (WC 89 06 01) Policy Number (WC 89 06 02) Effective Date (WC 89 06 03) Expiration Date (WC890604) Insured's Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer's Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured's Legal Status (WC 89 06 10) is changed to read: Item 4. Change To: Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate Per $100 Remuneration Estimated Annual Premium Total Estimated Annual Premium $ Minimum Premium $ Deposit Premium $ * of All other terms and conditions of this policy remain unchanged. NCCI Carrier Code No. 2001 National Council on Compensation Insurance. WC 890600 B WC 890600 B (Ed. 7-01) Item 3.C. States (WC 89 06 13) Item 3.A. States (WC 89 06 11) Item 3.B. Limits (WC 89 06 12) Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15) Interim Adjustment of Premium (WC 89 04 16) Carrier Servicing Office (WC 89 06 17) Interstate/Intrastate Risk ID Number (WC 89 06 18) Carrier Number (WC 89 06 19) Issuing Agency/Producer Office Address (WC 89 06 25) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of Effective Inception added WOS in favor of FIND Food Bank for $200 07/01/2020 SATIS0022500 Food in Need of Distribution, Inc. Service American Indemnity Company 38369 07/01/2020 07/01/2021 11 1,000 35,130 New Estimated Premium Less Previously Billed Additional Due 152.00 35,130.00 34,978.00 152.00 New Estimated Tax Less Previously Billed Additional Due 1,204.00 1,197.00 7.00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA Wehave the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022500 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2020 07/01/2020 07/01/2021 11 FIND Food Bank City of La Quinta, 78495 Calle Tampico, La Quinta, CA 0.050 FIND Food Bank City of La Quinta, 78495 Calle Tampico, La Quinta, CA 92253 and its officers, employees, agents, and volunteers Concerning a contract to distribute food. All Operations of the Named Insured as requested by the certholder. 5.0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 4/30/2020 Arthur J.Gallagher Risk Management Services,Inc. 2850 Golf Road Rolling Meadows IL 60008 Jeremiah Polk 630-773-3800 630-285-4062 License#:BR-724491 Philadelphia Indemnity Insurance Company 18058 FOODINN-01 Carolina Casualty Insurance Company 10510FoodInNeedofDistribution,Inc. 83-775 Citrus Avenue Indio CA 92202 New York Marine And General Insurance Company 16608 49229391 A X 1,000,000 X 100,000 5,000 1,000,000 3,000,000 X PHPK2074042 12/15/2019 12/15/2020 3,000,000 A 1,000,000 X PHPK2074042 12/15/2019 12/15/2020 A X X 3,000,000PHUB70422912/15/2019 X 12/15/2020 3,000,000 $10,000 C WC201900017211 7/1/2019 7/1/2020 1,000,000 1,000,000 1,000,000 B Directors &Officers DCP-1795595-P1 12/15/2019 12/15/2020 LIMIT $1,000,000 City of La Quinta,CA and all of its officers,employees,agents,and volunteers is listed as additional insured with respect to General Liability coverage. City of La Quinta 78495 Calle Tampico La Quinta,CA 92253 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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 shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. PHPK2074042 Name Of Additional Insured Person(s) Or Organization(s): City of La Quinta 78495 Calle Tampico,La Quinta,CA 92253 and its officers, employees, agents, and volunteers 15 97 POLICY CHANGE DOCUMENT POLICY NO.: CHANGE EFFECTIVE CHANGE #5(9,6,21 DESCRIPTION PHPK2074042 404/30/2020 05/01/2020____________________Issue Date 4 Added: Additional Insured City of La Quinta, and its officers, employees, agents, and volunteers 78495 Calle Tampico La Quinta, CA 92253 Form PI-GL-005 Addl Insured Primary & Non-Contributory Ins With respect to Food Distribution Per attached schedule Page 1 of 1 Philadelphia Indemnity Insurance Company NAMED INSURED 2648 ARTHUR J. GALLAGHER RISK MANAGEME Find Food BankFood In Need of Distribution, Inc. MAILING ADDRESS PO Box 10080Indio, CA 92202-2507 POLICY PERIOD:FROM TO at 12:01 A.M. Standard Time at your mailing address shown above. Path ID 13736919 0.00 NO CHANGE COUNTERSIGNED BY (Date)(Authorized Representative) 12/15/2019 12/15/2020 In consideration of the premium reflected, the policy is amended as indicated below: Total Annual 0.00Additional/Return Premium $Additional/Return Premium $ Total Prorate NO CHANGE Insurance Policy PI-GL-005 (07/12) Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission. 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: 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. City of La Quinta, and its officers, employees, agents, and volunteers 78495 Calle Tampico La Quinta, CA 92253 04/30/2020 1 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT−−−−CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be _____ % of the California workers’ compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No.Endorsement No. Insured Insurance Company Countersigned By 5.00 FIND Food Bank New York Marine and General Insurance Company / 28746 FIND Food Bank City of La Quinta, 78495 Calle Tampico, La Quinta, CA 92253 and its officers, employees, agents, and volunteers Concerning a contract to distribute food. All Operations of the Named Insured as requested by the certholder. 1WC201900017211 Food in Need of Distribution, Inc. 2020-04-01