Loading...
Insurance Certificates 2020/21 FIND Food BankINSURANCE 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: ________________________ Amendment #1 to the CSA with FIND Food Bank 02/09/2021 ✔ ✔ ✔ ✔ ✔ Monika Radeva 2/22/2021 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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© 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 Name Of Additional Insured Person(s) Or Organization(s): 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. PHPK2215397 City of La Quinta and its officers, employees, agents and volunteers 11 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 11 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 anyoneliable for an injury covered by this policy. We will not enforce our right against the person or organizationnamed 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. 02/09/2021 07/01/2020 07/01/2021 11 0.050 City of La Quinta, Community Resources Department 78495 Calle Tampico, La Quinta, CA 92253 DATE (MMIDD/YYYY) gQ�nm CERTIFICATE OF LIABILITY INSURANCE 12/14/2020 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: It 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 TACT NAME; Jeremiah Polk _ Arthur J. Gallagher Risk Management Services, Inc PHONE 630-773-3600 wX, No); 830-285-.40E2 2850 Golf Road Rolling Meadows IL 60008 ADD (LESS: INSURERS AFFORDING COVERAGE NAIC# _ INSURER A: Carolina Casual Insurance Company 10510 INSURED FOODINN-01 INSURER B : Service American Indemnity Company_ Food In Need of Distribution, Inc. INSURERC: Philadelphia Indemnity Insurance Company 18058 83-775 Citrus Avenue Indio CA 92202 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:17Fin79881 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' ADDLSUBRI POLICY EFF POLICY p(P T LTR TYPEOFINSURANCE 1 i} V I POLICY NUMBER (MMIDDIYYYY) I IMMJDDIYYYY i LIMITS C X COMMERCIAL GENERAL LIABILITY PHPK2215397 12/1512020 12/15/2021 EACHOCCURRENCE $1,000,000 X CLAIMS -MADE IJ OCCUR PREMISES Ea Docurrencei $100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY �EG7 LOG PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER! C AUTOMOBILE LIABILITY PHPK2215397 12/1512020 12/15/2021 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PRO RTYDAMA131= (1'e! ;cc gaol $ — - — HIRED NON -OWNED AUTOS ONLY H1AUTOS ONLY $ C X UMBRELLA LIAB X OCCUR PHUB749260 12/1512020 12/15/2021 EACH OCCURRENCE $3,000,000 AGGREGATE $ 3.000,000 EXCESS LIAB CLAIMS MADE X , ❑ED I X I RETENTION $ Is B WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR!PARTNERIEXECUTIVE Y SATIS0022500 7/1/2020 - 711/2021 ER 011-1- X STATUTE ER E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) NIA E.L. DISEASE - EA EMPLOYEE $1,000,000 II yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Directors&officers Professional Liability�7 DCP-1795595-P2 12/1512020 12/15/2021 LIMIT AGGREGATE LIMIT $1,006,000 $2.000.000 DESCRIPTION OF OPERATIONS r LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is requlred) 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. Waiver of Subrogation applies to certificate Bolder, as respects to the Workers Compensation policy, pursuant to and subject to the policy's terms, definitions, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION City of La Quinta 78495 Calle Tampico La Quinta CA 92253 USA 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 REPRESENd. TATIVE & CK 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2' of 2 4077 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