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Insurance Certificates 2020/21 NV5, IncINSURANCE 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 related to Amendment No. 1 with NV5, Inc. for On-Call Construction Surveying Services 2/17/2021 ✔ ✔ ✔ ✔ ✔ Monika Radeva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arrier: The Continental Insurance Co. Effective: 5/1/20-5/1/21 Policy Number: C 6057092160 Blanket Policy Limit: $6,907,532 Limit Per Item: $300,000 Blanket Short-Term Equipment Leased, Borrowed, or Rented From Others Limit: $100,000 Per occurrence/item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³DULVLQJRXWRI´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lobal, Inc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lobal, Inc. &RS\ULJKW&1$$OO5LJKWV5HVHUYHG,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Information required to complete this Schedule, if not shown above, will be shown in the Declarations. It is understood and agreed that the condition entitled Transfer Of Rights Of Recovery Against Others To The Insurer is amended by the addition of the following: Solely with respect to the person or organization shown in the Schedule above, the Insurer waives any right of recovery the Insurer may have against such person or organization because of payments the Insurer makes for injury or damage arising out of the Named Insured’s ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard. All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. SCHEDULE Name Of Person Or Organization: Any person or organization against whom you have agreed to waive such right of recovery in a written contract or agreement. Policy No: 6057040530 CNA71527XX (Ed. 10/12) ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY It is understood and agreed that this endorsement amends the BUSINESS AUTO COVERAGE FORM as follows: SCHEDULE Name of Additional Insured Persons Or Organizations AS REQUIRED BY CONTRACT 1. In conformance with paragraph A.1.c. of Who Is An Insured of Section II - LIABILITY COVERAGE, the person or organization scheduled above is an insured under this policy. 2. The insurance afforded to the additional insured under this policy will apply on a primary and non -contributory basis if you have committed it to be so in a written contract or written agreement executed prior to the date of the "accident" for which the additional insured seeks coverage under this policy. All other terms and conditions of the Policy remain unchanged. CNA71527XX (10/12) Policy No: BUA 6057040575 Page 1 of 1 Endorsement No: Effective Date: 05/01/2020 Insured Name: NV5 GLOBAL, INC. Copyright CNA All Rights Reserved. 00020007560570405758533 POLICY NUMBER: COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Name(s) Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. BUA 6057040575 NV5 Global, Inc 05/01/2020 ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE SUCH RIGHT OF RECOVERY IN A WRITTEN CONTRACT OR AGREEMENT. 3ROLF\ 1R :& 20 Policy No. WC 6 57040558