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Insurance Certificates 2021/22 Nichols ConsultingINSURANCE 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: ________________________ SB 90/State mandated cost reimbursement claim preparation services with Nichols Consulting. ✔ ✔ ✔ ✔ ✔ ✔ ✔ Monika Radeva 10/21/2021 FE-6609 Printed in U.S.A. R3Y0 Policy No.: 90-CJ-W945-5 SECTION II ADDITIONAL INSURED ENDORSEMENT Policy No.: 90-CJ-W945-5 Named Insured: Andy Nichols DBA Nichols Consulting Additional Insured (include address): City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely because of your work performed for that Additional Insured shown above. Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a suit brought for damages for which you are provided coverage. The Primary Insurance coverage below applies only when there is an "X" in the box. Primary Insurance. The insurance provided to the Additional Insured shown above shall be primary insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to you. All other policy provisions apply. FE-6609 A� V CERTIFICATE OF LIABILITY INSURANCE ATE IMMIDI D07/19/2021rr1 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). PRODUCER Greg Jung Agency 708 Natoma Street, Suite 100 Folsom, CA 95630 Li CONTACT NAME: Greg Jun PHc No Ext : 916-608-0899 Farc No :916 608 8889 E-MAIL ADDRESS: INSURER{S) AFFORDING COVERAGE I ii INSURER A :,State Farm General Insurance Compary 25151 INSURED NICHOLS, ANDY INSURER B: State Farm Mutual Automobile Insurance Company 25178 INSURER C: State Farm Fire and Casualty Company 25143 DBA NICHOLS CONSULTING INSURER D : 1857 44TH ST SACRAMENTO CA 95819 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: 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 SU POLICY NUMBER MMIODIYYYY MMLDDIYYYY LIMITS A GENERAL LIABILITY �� 90.CJ-W945-5 04102/2021 04102l2022 EACH OCCURRENCE $ 2,000.000 PREMISES Ea occurrence $ 300,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX7 OCCUR I EXP (Any one person) $ 5,000 PERSONAL & ACV INJURY S 2,000,000 GENERAL AGGREGATE 1 S 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG S 4,000.000 S X POLICY X PE O X LOC. I I AUTOMOBILE LIABILITY ❑ ❑ COMBINED SINGLE LIMIT Ea accident $ ANY AUTO 225 1177-D19-55K 04/19/2021 10/1912021 BODILY INJURY (Per person) S 1,000,000 BODILY INJURY (Per accident) S 1,000.000 SCHEDULED AUTOS AUTOS ALL OWNED Ix WX HIRED AUTOSNON-ONED AUTOS PeOaccRdenpAMAGE $ 1,000,000 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRCPRIETORIPARTNERrEXECUTIVE Y7 CFFICEWEMBER EXCLUDED? (Mandatory in Ni 111 A ❑ X WC STATU- I JOTH- TO T ER E.L. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYE $ E,L.DISEASE- POLICY LIMIT $ If yes, describe under A Protessiorar Liability-E&O ❑ ❑ 3726-708 04l79l2021 04l1912022 2,000,400 Each Occurrence DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 1111, Additional Remarks Schedute, if more space is required) Additional Insured. City of La Quinta 78495 Calle Tampico La Quinta, CA 92293 rPPTIFIr.ATF HOI f7FR CANCELLATION City of La Quinta 78495 Calle Tampico SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. La Quinta, CA 92293 AUTHORIZED REPRESENTATIVE Ci Ta38 0 0 Ai (:UKNUKA I II All rlgrlt5 reservea. ACORD 25 (2010105) The ACORD name and logo are registered marks oUkORD 1001585 137643.3 12-21-2010 StateFarm STATE FARM GENERAL INSURANCE COMPANY A STOCK COMPANY WITH NAME OFFICES IN BLOOMINGTON, ILLINOIS DECLARATIONS AMENDED APR 12 2021 Rr�charxdsan9TX 75085-3925 Addl Insured -Section II Only M-12-3641-FA5B F N 001219 3123 CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA CA 92253-2839 IIIIII'I�II��II�IIII"'Illlllll'I'Illlllllllllllll��llll'Ill'Illl Office Policy Policy Number 90-CJ-W945-5 Policy Period Effective Date Expiration Date 12 Months APR 2 2021 APR 2 2022 The poll y period begins and ends at 12:01 am standard time at a premises location. Named Insured NICHOLS, ANDY DBA NICHOLS CONSULTING 1857 44TH ST SACRAMENTO CA 95819-4713 Automatic Renewal - If the policy period is shown as 12 months , this policy will be renewed automatically subjectto the premiums, rules and forms in effectfor each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law. Entity: Individual Reason for Declarations: Your policy is amended APR 12 2021 ADDITIONAL INSURED ADDED PREMIUM ADJUSTMENT FORM CMP-4786.1 ADDED Endorsement Premium Increase $ 44.00 Discounts Applied: Renewal Year Years in Business Claim Record Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 009795 290 Al Continued on Reverse Side of Page N Page 1 of 6 530-566 a.2 05-31-2011 (oI[3231c( DECLARATIONS (CONTINUED) Office Policy for CITY OF LA QUINTA Policy Number 90-CJ-W945-5 SECTION I - PROPERTY SCHEDULE Location Location of Limit of Insurance* Limit of Insurance* Seasonal Number Described Increase - Premises Coverage A - Coverage B - Business Buildings Business Personal Personal Property Property 001 1857 44TH ST No Coverage $ 11,700 25% SACRAMENTO CA 95819-4713 * As of the effective date of this policy, the Limit of Insurance as shown includes any increase in the limit due to Inflation Coverage. SECTION I - INFLATION COVERAGE INDEXES) Cov A - Inflation Coverage Index: Cov B - Consumer Price Index: SECTION I - DEDUCTIBLES N/A 260.4 Basic Deductible $1,000 Special Deductibles: Money and Securities $250 Employee Dishonesty $250 Equipment Breakdown $1,000 Other deductibles may apply - refer to policy. Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes Copyrighted material of Insurance Services Office, Inc., with its permission. 009795 Continued on Next Page Page 2 of 6 DECLARATIONS (CONTINUED) Office Policy for CITY OF LA QUINTA Policy Number 90-CJ-W945-5 SECTION I - EXTENSIONS OF COVERAGE - LIMIT OF INSURANCE - EACH DESCRIBED PREMISES s The coverages and corresponding limits shown below apply separately to each described premises Shown in these Declarations, unless indicated by "See Schedule." If a coverage does not have a corresponding limit shown below, �o but has "Included" indicated, please refer to that policy provision for an explanation of that coverage. LIMIT OF COVERAGE INSURANCE Accounts Receivable On Premises $50,000 Off Premises $15,000 Arson Reward $5,000 Back -Up Of Sewer Or Drain $15,000 Collapse Included Damage To Non -Owned Buildings From Theft, Burglary Or Robbery Coverage B Limit Debris Removal 25% of covered loss Equipment Breakdown Included Fire Department Service Charge $5,000 Fire Extinguisher Systems Recharge Expense $5,000 Forgery Or Alteration $10,000 Glass Expenses Included Increased Cost Of Construction And Demolition Costs (applies only when buildings are 10% insured on a replacement cost basis) Money And Securities (Off Premises) $5,000 Money And Securities (On Premises) $10,000 Money Orders And Counterfeit Money $1,000 Newly Acquired Business Personal Property (applies only if this policy provides $100,000 Coverage B - Business Personal Property) Newly Acquired Or Constructed Buildings (applies only if this policy provides $250,000 Coverage A - Buildings) Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 009796 290 Continued on Reverse Side of Page Page 3 of 6 N DECLARATIONS (CONTINUED) Office Polioy for CITY OF LA OUINTA Policy Number 90-CJ-W945-5 Ordinance Or Law - Equipment Coverage Outdoor Property Personal Effects (applies only to those premises provided Coverage B - Business Personal Property) Personal Property Off Premises Pollutant Clean Up And Removal Preservation Of Property Property Of Others (applies only to those premises provided Coverage B - Business Personal Property) Signs Unauthorized Business Card Use Valuable Papers And Records On Premises Off Premises Included $5,000 $5,000 $15,000 $10,000 30 Days $2,500 $2,500 $5,000 $50,000 $15,000 gFRTInN 1 - FXTFNi41nNS nF rnVFRAC,F F. I IMIT OF INSURANCE - PER POLICY The coverages and corresponding limits shown below are the most we will pay regardless of the number of described premises shown in these Declarations. COVERAGE Dependent Property - Loss Of Income Employee Dishonesty Utility Interruption - Loss Of Income Loss Of Income And Extra Expense LIMIT OF INSURANCE $5,000 $10,000 $10,000 Actual Loss Sustained - 12 Months Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc„ with its permission. 009796 Continued on Next Page Page 4 of 6 DECLARATIONS (CONTINUED) Office Policy for CITY OF LA QUINTA Policy Number 90-CJ-W945-5 SECTION II - LIABILITY g LIMIT OF o COVERAGE INSURANCE Coverage L - Business Liability $2,000,000 Coverage M - Medical Expenses (Any One Person) $5,000 Damage To Premises Rented To You $300,000 LIMIT OF AGGREGATE LIMITS INSURANCE Products/Completed Operations Aggregate $4,000,000 General Aggregate $4,000,000 Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II - Liability in the Coverage Form and any attached endorsements. Your policy consists of these Declarations, the BUSINESSOWNERS COVERAGE FORM shown below, and any other forms and endorsements that apply, including those shown below as well as those issued subsequent to the issuance of this policy. FORMS AND ENDORSEMENTS CMP-4101 Businessowners Coverage Form CMP-4786.1 *Addl Insd Owners Lessee Sched CMP-4787 *Waiver of Trans Rgt of Recov FE-6999.3 Terrorism Insurance Cov Notice CMP-4713.1 Excl Testing Consulting E&O CMP-4819.1 Unauthorized Business Card Use CMP-4698 Back -Up of Sewer or Drain CMP-4704.1 Dependent Prop Loss of Income CMP-4710 Employee Dishonesty CMP-4709 Money and Securities CMP-4703.1 Utility Interruption Loss Incm CMP-4705.2 Loss of Income & Extra Expense CMP-4260.1 Amendatory Endorsement -CA Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 009797 290 Continued on Reverse Side of Page N Page 5 of 6 DECLARATIONS (CONTINUED) Office Policy for CITY OF LA DUINTA Policy Number 90-CJ-W945-5 CMP-4261 Amendatory Endorsement FD-6007 Inland Marine Attach Dec NOTICE: INFORMATION CONCERNING CHANGES IN YOUR POLICY LANGUAGE IS INCLUDED. PLEASE CALL YOUR AGENT IF YOU HAVE ANY QUESTIONS. . New Form Attached This policy is issued by the State Farm General Insurance Company. Participating Policy You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance with the Company's Articles of Incorporation, as amended. In Witness Whereof, the State Farm General Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. *M,X- M.�� " �,4� Cm/# Secretary President IMPORTANT NOTICE: California law requires us to provide you with Information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Your agent's name and contact information are provided on the front of this document. Another option Is to reach out by mail or phone directly to: State Farm Executive Customer Service PO Box 2320 Bloomington IL 61702 Phone # 1-800-STATEFARM (1-800-782-8332) Department of Insurance complaints should be filed only after you and State Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Phone # 1-800.927-HELP (43M or visit www.insurance.ca.aovl01-consumers Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 009797 290 Page 6 of 6 N STATE FARM GENERAL INSURANCE COMPANY A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS INLAND MARINE ATTACHING DECLARATIONS POnx 8539?5 75085-3925 Poc ardsOr�, Named Insured M-12-3641-FA513 F N NICHOLS, ANDY DBA NICHOLS CONSULTING 1857 44TH ST �. SACRAMENTO CA 95819-4713 8 0 0 ATTACHING INLAND MARINE Policy Number 90-CJ-W945-5 Policy Period Effective Data Expiration Date 12 Months APR 2 2021 APR 2 2022 The poll y period begins and ends at 12:01 am standard time at a premises location. Automatic Renewal - If the policy period is shown as 12 months, this policy will be renewed automatically subjectto the premiums, rules and forms in effectfor each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law. Annual Policy Premium Included The above Premium Amount is included in the Policy Premium shown on the Declarations. Your policy consists of these Declarations, the INLAND MARINE CONDITIONS shown below, and any other forms and endorsements that apply, including those shown below as well as those issued subsequentto the issuance of this policy. Forms, Options, and Endorsements FE-8739 Inland Marine Conditions FE-6271 Amendatory Endorsement FE-8745 Inland Marine Computer Prop See Reverse for Schedule Page with Limits Prepared MAY 05 2021 © Copyright, State Farm Mutual Automobile Insurance Company, 2000 FD-6007 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 009798 530-666 a.2 05-31-2011 1o1F3232c1 90-CJ-W945-5 ATTACHING INLAND MARINE SCHEDULE PAGE ATTACHING INLAND MARINE ENDORSEMENT LIMIT OF DEDUCTIBLE NUMBER COVERAGE INSURANCE AMOUNT FE-8745 Inland Marine Computer Prop S 25,000 $ 500 Loss of Income and Extra Expense S 25,000 Prepared MAY 05 2021 FD-6007 OTHER LIMITS AND EXCLUSIONS MAY APPLY - REFER TO YOUR POLICY © Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc„ with its permission, ANNUAL PREMIUM Included Included 009798 530-666 a.2 05-31-2011 101323. 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 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. r(initial) OWLEDGMENT 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 ear. (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 gop orders. initial) 1 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' 9ensation Laws of California. (initial) I understand that California Labor Code § 3700 et seq. requires employers to provide p 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 nce because it has no employees. a (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 lifornia 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 14 day of January 2.21 at Sacramento California Signature o Declarant Andy Nichols Print Name of Declarant Nichols Consulting Print Name of Company .1 a, r Declaration of Sole Proprietor OF DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Nichols Consulting Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to Nichols Consulting as follows: I am the authorized representative of Nichols Consulting s an independent contractor for the purposes of the California Workers' Compensation and Labor laws. This organization will hire no employees other than the parents, spouses, or children of its board members for work required for any bid or contract awarded to Nichols Consulting . All worked required will be performed personally and solely by me, other board members of the organization, their parents, spouses or children, or persons who perform voluntary service without pay to the organization. If, however, the organization shall ever hire employees to perform this contract or any portion thereof, the organization shall obtain Workers' Compensation Insurance and provide proof of Workers' Compensation Insurance coverage to the City of La Quinta. If the organization shall ever hire a subcontractor to perform this contract or any portion thereof, and the subcontractor has employees, then the organization shall require its subcontractor to obtain Workers' Compensation Insurance Coverage, or the organization shall obtain Workers' Compensation Coverage for that subcontractor's employees. This document constitutes a declaration by the organization against its financial interest, relative to any claims it should assert under the California Workers' Compensation and/or Labor laws against City of La Quinta relating to any bid or contract awarded to Nichols Consulting The organization will defend, indemnify and hold harmless the City of La Quinta from any and all claims and liability, including Workers' Compensation claims and liability that may be asserted or established by any party in the event the organization hires an employee in violation of this addendum, and the organization will further indemnify the City of La Quinta for all damages the City of La Quinta thereby suffers. I agree that these dtecI atipns shall constitute an addendum to any bid or contracts awarded to U January 14, 2021 Date Authorized