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Insurance Certificates 2020/21 SCOPE EventsINSURANCE REVIEW Cu Qa�&a RE: Amendment 2 with Scope Events to reschedule the March 2021 La Quinta Art Celebration to November 2021; all terms and financial obligations transferred. 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 12/16/2020 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: F-1$1,000,000 per occurrence/loss Other: List other insurance types such as - molestation, harassment, etc. Approved by: Date: Monika Radeva February 24, 2021 / ACC " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 2i22i2021 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 Gaspar Insurance Services, Inc. 23161 Ventura Blvd, Suite 100 Woodland Hills CA 91364 CONTACT NAME: PHONE FAX A/C No Ext : 818-302-3060 A/C No), ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: PHILADELPHIA INDEMNITY INSURAN 18058 License#: OG66626 INSURED SCOPEVE-01 Scope Events LLC 25850 River road INSURERB: California Automobile Insuranc 38342 INSURER C : Landmark American Insurance Co 33138 INSURER D : Cloverdale CA 95425 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 1075490541 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y PHPK2170477 10/8/2020 10/8/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR TED PREMISES (Ea oDAMAGE TO ccurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY ❑ PRO- JECT ❑ LOC X PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y BA040000055197 10/8/2020 10/8/2021 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C PROFESSIONAL LIABILITY LHR84200 3/1/2021 3/1/2022 EACH CLAIM LIMIT $ 1,000,000 AGGREGATE LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of La Quinta is hereby additional insured. Coverage is Primary & Non -Contributory. Waiver of Subrogation is in favor of City of LA Quinta. Please refer to the attached endorsements. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of La Quinta 78495 Calle Tampico La Quinta, CA AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ,4cvRo0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/16/2020 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 Gaspar Insurance Services, Inc. 23161 Ventura Blvd, Suite 100 Woodland Hills CA 91364 CONTACT NAME: PHONE FAX /c No Ext : 818-302-3060 A/C No): WC, ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: PHILADELPHIA INDEMNITY INSURAN 18058 License#: OG66626 INSURED SCOPEVE-01 Scope Events LLC 25850 River road INSURER B : California Automobile Insuranc 38342 INSURER C INSURER D Cloverdale CA 95425 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:289168307 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y PHPK2170477 10/8/2020 10/8/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREM SES (Ea occurrrence $100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO - POLICY JECTPRO ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y BA040000055197 10/8/2020 10/8/2021 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED �( NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A PROFESSIONAL LIABILITY PHPK2170477 10/8/2020 10/8/2021 EACH INCIDENT LIMIT $ 1,000,000 AGGREGATE LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of La Quinta is hereby additional insured. Coverage is Primary & Non -Contributory. Waiver of Subrogation is in favor of City of LA Quinta. Please refer to the attached endorsements. CERTIFICATE HOLDER CANCELLATION City of La Quinta 78495 Calle Tampico La Quinta, CA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �� •3' © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK2170477 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 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. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Philadelphia Indemnity Insurance Company Additional Insured Schedule Policy Number: PHPK2170477 Additional Insured City of La Quinta 78495 Calle Tampico La Quinta, CA 92253-2839 CG2026 - General Liability Page 1 of PI-GL-005 (07/12) 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: 10/08/2019 Name of Person or Organization (Additional Insured): City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 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. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 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 withAfky 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 —Afl(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. Ajf"(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. (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. Ofv (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 20_ at , California Signature of Declarant Print Name of Declarant Print Name of Company PHILADELPHIA INDEMNITY INSURANCE COMPANY 1-877-438-7459 ONE BALA PLAZA, SUITE 100 BALA CYNWYD PA 19004 REINSTATEMENT NOTICE Named Insured & Mailing Address: Producer: 0117283 SCOPE EVENTS LLC GASPAR INSURANCE 25850 RIVER RD 23161 VENTURA BLVD STE 100 CLOVERDALE CA 95425-4338 WOODLAND HILLS CA 91364-1186 Policy No.: PHPK2311444 Type of Policy: FP :FOR PROFIT SOCIAL SERVICE PKG You recently received a notice advising this policy was being cancelled effective 11/15/2021 . This notice is to advise that the policy is being reinstated without lapse in coverage. Other Party of Interest CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA CA 92253 Date Mailed: 27t51L ct b. r, 2021 JOAN HILLMAN FORM# CT969897CA51995 ODEN 3,0.21.08a 0001069-0002144 Copy for Other Interests CACT36 10262021 SNNY Page 1 of 1 PHILADELPHIA INDEMNITY INSURANCE COMPANY 1-877-438-7459 ONE BALA PLAZA, SUITE 100 BALA CYNWYD PA 19004 REINSTATEMENT NOTICE Named Insured & Mailing Address: Producer: 0117283 SCOPE EVENTS LLC GASPAR INSURANCE PO BOX 104 23161 VENTURA BLVD STE 100 LA QUINTA CA 92247-0104 WOODLAND HILLS CA 91364-1186 I Policy No.: PHPK2170477 Type of Policy: FP :FOR PROFIT SOCIAL SERVICE PKG You recently received a notice advising this policy was being cancelled effective 11/16/2020 - This notice is to advise that the policy is being reinstated without lapse in coverage. Other Party of Interest +rCITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA CA 92253 Date Mailed: r 8th of De r, 2020 JOAN HILLMAN FORM# CT969897CA51995 ODEN 30.20-10a 0000634-0001268 Copy for Other Interests CACT36 12072020SNNY Page 1 of 1 PHILADELPHIA INDEMNITY INSURANCE COMPANY 1-877-438-7459 ONE BALA PLAZA, SUITE 100 BALA CYNWYD PA 19004 NOTICE OF CANCELLATION OF INSURANCE Named Insured & Mailing Address: SCOPE EVENTS LLC 25850 RIVER RD CLOVERDALE CA 95425-4338 Producer:0117283 GASPARINSURANCE 23161 VENTURA BLVD STE 100 WOODLAND HILLS CA 91364-1186 Policy No.: PHPK2311444 Type of Policy: FP :FOR PROFIT SOCIAL SERVICE PKG Date of Cancellation: 11/15/2021; 12:01 A.M. Local Time at the mailing address of the Named Insured. We are cancelling this policy. Your insurance will cease on the Date of Cancellation shown above. The reason for cancellation is NONPAYMENT OF PREMIUM 862.00. This policy provides basic property insurance on your property. You should contact your agent concerning coverage through another insurer, or your eligibility for coverage through the California Fair Plan, P.O. Box 76924, Los Angeles, CA 90076, Phone: (800) 339-4099 or www.cfpnet.com. Your interest in this policy as an "insured" or other party of interest is being cancelled effective 11/15/2021; 12:01 A.M. Local Time at the mailing address of the named insured. Other Party of Interest CITY OF LA QUINTA F 78495 CALLE TAMPICO LA QUINTA CA 92253 Date Mailed: 25t y of Oct bi r, 2021 JOAN HILLMAN FORM# CC969701 CA102020 ODEN 3.0.21.08a 0000242-0000513 Copy for Other Interests CACC36NONPMNT 10232021 MYNY Page 1 of 1 PHILADELPHIA INDEMNITY INSURANCE COMPANY 1-877-438-7459 ONE BALA PLAZA, SUITE 100 BALA CYNWYD PA 19004 NOTICE OF CANCELLATION OF INSURANCE Named Insured & Mailing Address SCOPE EVENTS LLC PO BOX 104 LA QUINTA CA 92247-0104 Producer:0117283 GASPARINSURANCE 23161 VENTURA BLVD STE 100 WOODLAND HILLS CA91364-1186 Policy No.: PHPK2170477 Type of Policy: FP :FOR PROFIT SOCIAL SERVICE PKG Date of Cancellation: 11/16/2020; 12:01 A.M. Local Time at the mailing address of the Named Insured. We are cancelling this policy. Your insurance will cease on the Date of Cancellation shown above. The reason for cancellation is NONPAYMENT OF PREMIUM 818.00. This policy provides fire and extended coverage insurance on your property. You should contact your agent concerning coverage through another insurer, or your eligibility for coverage through the California Fair Plan, P.O. Box 76924, Los Angeles, CA 90076, Phone: (800) 339-4099 or www.cfpnet.com. Your interest in this policy as an "insured" or other party of interest is being cancelled effective 11/16/2020; 12:01 A.M. Local Time at the mailing address of the named insured. Other Party of Interest " CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA CA 92253 Date Mailed: r 26t y of Oct bi r, 2020 JOAN HUMAN CACC36NONPMNT FORM# CC969701 CA1 12017 10242020MYNY ODEN 3.0 20 10a Copy for Other Interests Page 1 of 1 PN / ACC " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 2/27/2020 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 Gaspar Insurance Services, Inc. 23161 Ventura Blvd, Suite 100 Woodland Hills CA 91364 CONTACT NAME: Nick Charton PHONE FAX A/C No Ext : 818-302-3060 A/C No), ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Philadelphia Indemnity Insuran 18058 License#: OG66626 INSURED SCOPEVE-01 Scope Events LLC 25850 River road INSURERB: California Automobile Insuranc 38342 INSURER C : Landmark American Ins. Co. INSURER D : Cloverdale CA 95425 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1969246512 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS A COMMERCIAL GENERAL LIABILITY Y Y EV63883 3/1/2020 3/14/2020 EACH OCCURRENCE $2,000,000 F —V� CLAIMS -MADE OCCUR DAMAGE TO PREMISESa oNcur ence)$ ('a 300,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY ❑ PRO- JECT ❑ LOC PRODUCTS - COMP/OP AGG $ 4,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y BA040000055197 10/8/2019 10/8/2020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB X OCCUR PHUB712453 3/1/2020 3/14/2021 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C Professional Liability LHR839660 3/1/2020 3/1/2021 Each Claim 1,000,000 Professional Liability Aggregate 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EVENT: LA Quinta Art Celebration 3/2/19 - 3/9/20 This policy includes a blanket endorsement. City of La Quinta is hereby additional insured. Coverage is Primary & Non -Contributory. Waiver of Subrogation is in favor of City of LA Quinta. Please refer to the attached endorsements. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 AUTHORIZED REPRESENTATIVE w ©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. Business Auto Broadening Endorsement This endorsement modifies insurance provided under the following: I. NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED) II. EMPLOYEES AS INSUREDS III. AUTOMATIC ADDITIONAL INSURED IV. EMPLOYEE HIRED AUTO LIABILITY V. SUPPLEMENTARY PAYMENTS VI. FELLOW EMPLOYEE COVERAGE VII. ADDITIONAL TRANSPORTATION EXPENSE VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE X. LOAN/LEASE GAP COVERAGE XI. GLASS REPAIR — DEDUCTIBLE WAIVER XII. TWO OR MORE DEDUCTIBLES XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS XIV. WAIVER OF SUBROGATION XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT XVIII. HIRED AUTO — COVERAGE TERRITORY XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 1 of 6 BUSINESS AUTO COVERAGE FORM I. NEWLY ACQUIRED OR FORMED ENTITY (Broad Form Named Insured) SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: d. Any business entity newly acquired or formed by you during the policy period provided you own 50% or more of the business entity and the business entity is not separately insured for Business Auto Coverage. Coverage is extended up to a maximum of 180 days following acquisition or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. Coverage does not apply to an "accident" which occurred before you acquired or formed the organization. II. EMPLOYEES AS INSUREDS SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: e. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. III. AUTOMATIC ADDITIONAL INSURED SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: f. Any person or organization that you are required to include as additional insured on the Coverage Form in a written contract or agreement that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. IV. EMPLOYEE HIRED AUTO LIABILITY SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: g. An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. V. SUPPLEMENTARY PAYMENTS SECTION II — LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a. Supplementary Payments, Subparagraphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We are not obligated to furnish these bonds. (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 2 of 6 VI. FELLOW EMPLOYEE COVERAGE: SECTION II — LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee This exclusion does not apply if you have workers' compensation insurance in -force covering all of your "employees". Coverage is excess over any other collectible insurance. VII. ADDITIONAL TRANSPORTATION EXPENSE SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Transportation Expenses, is replaced with the following: We will pay up to $SO per day to a maximum of $1000 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". If your business shown in the Declarations is other than an auto dealership, we will also pay up to $1,000 for reasonable and necessary costs incurred by you to return a stolen covered auto from the place where it is recovered to its usual garaging location. VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, the following is added: C. If Liability Coverage is provided in this policy on a Symbol 1 or a Symbol 8 basis and Comprehensive, Specified Causes of Loss, or Collision coverages are provided under this coverage form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire, subject to the following limit: (1) The most we will pay for "loss" to any hired "auto" is $50,000 or Actual Cash Value or Cost of Repair, whichever is less (2) $500 deductible will apply to any loss under this coverage extension, except that no deductible shall apply to "loss" caused by fire or lightning Subject to the above limit and deductible we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own of similar size and type. This coverage extension is excess coverage over any other collectible insurance. IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a., is amended to add the following: This exclusion does not apply to the accidental discharge of an airbag. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 3 of 6 X. LOAN/LEASE GAP COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added: 4. In the event of a "total loss" to a covered "auto" shown in the schedule or declarations for which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on the lease or loan for that covered "auto," less: a. The amount paid under the Physical Damage Coverage Section of the policy; and b. Any: (1) Overdue lease/loan payments at the time of the "loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage. (3) Security deposits not returned by the lessor; (4) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5) Carry-over balances from previous loans or leases. The most we will pay under Auto Loan/Lease Gap Coverage for an insured auto is 25% of the actual cash value of that insured auto at the time of the loss. XI. GLASS REPAIR — DEDUCTIBLE WAIVER SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. XII. TWO OR MORE DEDUCTIBLES SECTION III -PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: If two or more "company" policies or coverage forms apply to the same accident: 1. If the applicable Business Auto deductible is the smallest, it will be waived; or 2. If the applicable Business Auto deductible is not the smallest, it will be reduced by the amount of the smallest deductible; or 3. If the loss involves two or more Business Auto coverage forms or policies the smallest deductible will be waived. For the purpose of this endorsement "company" means the company providing this insurance and any of the affiliated members of the Mercury Insurance Group of companies. XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The requirement in SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit, Or Loss, a., In the event of "accident", you must notify us of an "accident" applies only when the "accident" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) A member, if you are a limited liability company; or (4) An executive officer or insurance manager, if you are a corporation. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 4 of 6 XIV. WAIVER OF SUBROGATION SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 5. Transfer of Rights Of Recovery Against Others To Us, section is replaced by the following: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of the operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment, Misrepresentation, or Fraud, the following is added: Any unintentional omission of or error in information given by you, or unintentional failure to disclose all exposures or hazards existing as of the effective date or at anytime during the policy period shall not invalidate or adversely affect the coverage for such exposure or hazard or prejudice your rights under this insurance. However, you must report the undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. This provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. For Hired Auto Physical Damage Coverage, is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: 1. Any covered "auto" you lease, hire, rent or borrow; and 2. Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, the following is added and supersedes any provision to the contrary: 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. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 5 of 6 XVIII. HIRED AUTO - COVERAGE TERRITORY SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 7. Policy Period, Coverage Territory, e. Anywhere in the world if:, is replaced by the following: e. Anywhere in the world if: (1) A covered "auto" is leased, hired, rented or borrowed without a driver for a period of 30 days or less; and (2) The "insured's" responsibility to pay damages is determined in a "suit" on the merits, in the United States of America, the territories and possessions of the United States of America, Puerto Rico, or Canada or in a settlement we agree to. XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH SECTION V — DEFINITIONS, C. "Bodily Injury' is amended by adding the following: "Bodily injury" also includes mental anguish but only when the mental anguish arises from other bodily injury, sickness, or disease. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 6 of 6 POLICY NUMBER: EV63883 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: The City of La Quinta 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 we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ PI-SE-007 (11/11) 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: 03/01 /2020 Name of Person or Organization (Additional Insured): The City of La Quinta 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. Page of 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: EV63883 COMMERCIAL GENERAL LIABILITY CG20120413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION -PERMITS OR AUTHORIZATIONS PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of La Quinta 78-495 Calle Tampico, La Quinta, CA 92253 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 any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b.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. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". 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 CG 20 12 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: EV63883 COMMERCIAL GENERAL LIABILITY CG 20 12 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of La Quinta 78-495 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 insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or au- thorization. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". CG 20 12 05 09 © Insurance Services Office, Inc., 2012 Page 1 of 1 PI-GL-005 (07/12) 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: 10/08/2019 Name of Person or Organization (Additional Insured): City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 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. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 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.g❑. 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 surh stop orders. initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta ( a will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' Compensation Laws of California. (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 in urance 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 1 hire employees in the future, I will immediately notify City of La Quinta and provide a ce ified 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. if Executed this IV / day of L.� 209at F ,a--(fA Gc �J California re of Declarant Print Name of Declarant Print Name of Company