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Insurance Certificates 2019/21 Vintage ElectricINSURANCE REVIEW RE: 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 _____________________________ 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: ________________________________________________________ List other insurance types such as – molestation, harassment, etc. Approved by: ________________________ Date: ________________________ Insurance for Vintage Electric Agreement for Contract Services to provide On-Call Electrical Services. 8/17/2020 ✔ ✔ ✔ ✔ ✔ ✔ GL or Umbrella of $5M/$5M Monika Radeva 8/26/2020 Vintage Electric ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person)$ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $AUTOS (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $$ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01) CERTIFICATE OF LIABILITY INSURANCE Colony Insurance Comp 8/31/2020 Professional Insurance Associates PO Box 1266 San Carlos, CA 94070 License#:0G30638 (909) 337-9437 (909) 494-8338 bob@hesslerinsurance.com Vintage Electric Vintage E & S, Inc. 49950 Jefferson St. 130-388 Indio, CA 92201 (760)775-0135 Colony Insurance Comp ICW Mercury Insurance Colony Insurance Comp A X X X 103GL0031522-00 9/27/19 9/27/20 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 C X X X BA 040000035434 8/14/20 8/14/21 1,000,000 D X X XS4247167 9/27/19 9/27/20 5,000,000 5,000,000 B N WPL 5053943 00 2/24/20 2/24/21 X 1,000,000 1,000,000 1,000,000 Certificate Holder is named Additional Insured as their interest may appear pursuant to written agreement. Blanket Additional Insured applies. This insurance is Primary and Non-Contributory. Waiver of subrogation applies to Workers Compensation. City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 jmignogna@laquintaca.gov Colony Insurance Comp INSURED D I V I D E R P A G E Producer No: 0001655 SAN: 39195010000000 Pol Eff Dt: 02-24-2020 Office: 24 Date Printed: 08-26-2020 Time Printed: 11:26:33 Trans Eff Dt: 02-24-2020 Insured Name: VINTAGE E & S INC Policy No: WPL5053943 Trans Seq No: 004 Trans Type: Change Endorsement Oper Init: ALOPEZ- Company Abbr: IW Release Version: 20.10 User-Selected Sets Copies Printer INSURED COPY 01 PDF ONLY COMPANY COPY 01 PDF ONLY BUREAU COPY 01 PDF ONLY INSURED 08-26-20 VINTAGE E & S INC 49950 JEFFERSON ST. 130-388 INDIO CA 92201 INSURED The following item(s) Insured’s Name (WC 89 06 01) Item 3.B. Limits (WC 89 06 12) Policy Number (WC 89 06 02) Item 3.C. States (WC 89 06 13) Effective Date (WC 89 06 03) Item 3.D. Endorsement Numbers (WC 89 06 14) Expiration Date (WC 89 06 04) Item 4. *Class, Rate, Other (WC 89 04 15) Insured’s Mailing Address (WC 89 06 05) Interim Adjustment of Premium (WC 89 04 16) Experience Modification (WC 89 04 06) Carrier Servicing Office (WC 89 06 17) Producer’s Name (WC 89 06 07) Interstate/Intrastate Risk I.D. Number (WC 89 06 18) Change in Workplace of Insured (WC 89 06 08) Carrier Number (WC 89 06 19) Insured’s Legal Status (WC 89 06 10) Issuing Agency/Producer Office Address (WC 89 06 25) Item 3.A. States (WC 89 06 11) X X POLICY INFORMATION PAGE ENDORSEMENT 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 Premium: Insurance Company Countersigned By SEE ATTACHED WC 99 06 54 (03-08) EXTENSION WPL 5053943 00 02-24-20 003 INSURANCE COMPANY OF THE WEST WAIVED UNTIL AUDIT VINTAGE E & S INC THE POLICY IS AMENDED AS FOLLOWS: AMENDED POLICY TO ADD WAIVER OF SUBROGATION FOR: CITY OF LA QUINTA 78-495 CALLE TAMPICO LA QUINTA, CA 92253 GENERAL ELETRICAL MAINTENANCE 500 11,627 INSURED WC 00 00 01A Page 1 (Ed. 6-16) Issue Date: PO Box 509039 San Diego, CA 92150-9039 Standard Workers’ Compensation and Employers’ Liability Policy Named Insured: Policy Number: Agent Name: Policy Period: To Agent No: Schedule: Waiver No. Class Job No. Job Description Payroll Rate Premium WPL 5053943 00 02-24-2020 02-24-2021 08-26-20 INSURANCE COMPANY OF THE WEST 0001655 VINTAGE E & S INC PROFESSIONAL INSURANCE ASSOCIA CALIFORNIA - WAIVER OF SUBROGATION 1 5140 ELECTRICAL MAIN GENERAL ELECTRICAL $ 0 0.1495 $ 0.00 MAINTENANCE 1 To Equal Minimum Premium $ 50.00 CALIFORNIA - Waiver of Subrogation Total $ 50.00 Page 1 INSURED 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 Premium $ Insurance Company Countersigned By WPL 5053943 00 02/24/2020 003 INSURANCE COMPANY OF THE WEST VINTAGE E & S INC INCL. WC 99 06 37 (Ed. 5-02) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 37 (Ed. 5-02) 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, subject to a minimum premium of . Schedule Person or Organization Job Description CITY OF LA QUINTA ELECTRICAL MAINTENANCE 5 $ 50 78-495 CALLE TAMPICO CITY LIMITS OF LA QUINTA LA QUINTA, CA 92253 GENERAL ELECTRICAL MAINTENANCE