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Insurance Certificates 2022/23 HR Green Pacific 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: ________________________ HR Green Pacific insurance for on-call public works inspection services. 8/24/2022 ✔ ✔ ✔ ✔ Monika Radeva 8/30/2022 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-MAIL ADDRESS: 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 ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR 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 ACORD HIRED AUTOS ONLY 01/01/22 Ashley Hampsher 4,000,000 201 First Street SE, Suite 700 (Claims Made Coverage) 78-495 Calle Tampico Professional Liability X 0//2022 2,000,000 X 10,000 01/01/22 01/01/23 1,000,000 X 4,000,000 X 319-896-7664 X Aggregate 10,000 CUP8S97473322NF Per Claim 01/01/23 10,000,000 La Quinta, CA 92253 01/01/23 01/01/22 A DPR9987508 1-800-300-0325 X 10,000,000 by written contract with the insured, per policy terms and conditions. City of La Quinta is an Additional Insured on the General Liability on a primary and non-contributory basis as required 01/01/22 Corona, CA 92879-5013 City of La Quinta Suite 305 1260 Corona Point Court BAP373096812 01/01/22 X ahampsher@holmesmurphy.com X 1,000,000 HR Green Pacific, Inc. 2,000,000 WC373096612 GLO373096712X Cedar Rapids, IA 52401 XL SPECIALTY INS CO A Travelers Property Casualty Company of Zurich American Insurance Company X A 300,000 Attn: Maria Casillas 01/01/23 65706021 65706021 C N X B 1,000,000 37885 USA 25674 16535 2,000,000 rolsoncr 01/01/23 10,000,000 5,000,000 Holmes Murphy & Assoc - CR $GGLWLRQDO,QVXUHG±$XWRPDWLF±2ZQHUV/HVVHHV2U &RQWUDFWRUV 3ROLF\1R (II'DWHRI3RO ([S'DWHRI3RO (II'DWHRI(QG 3URGXFHU1R $GG¶O3UHP 5HWXUQ3UHP 7+,6(1'256(0(17&+$1*(67+(32/,&<3/($6(5($',7&$5()8//< 7KLVHQGRUVHPHQWPRGLILHVLQVXUDQFHSURYLGHGXQGHUWKH &RPPHUFLDO*HQHUDO/LDELOLW\&RYHUDJH3DUW $6HFWLRQ,, ±:KR,V$Q,QVXUHG LVDPHQGHGWRLQFOXGHDVDQDGGLWLRQDO LQVXUHGDQ\SHUVRQRURUJDQL]DWLRQZKRP\RX 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LQVXUHGVXQGHUWKLVHQGRUVHPHQW WKHIROORZLQJLVDGGHGWR 6HFWLRQ ,,,±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lease 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: ________________________ DATE (MMIDDIYYYY) C�Ro� CERTIFICATE OF LIABILITY INSURANCE 06/02/2022 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 1-800-300-0325 NAME, Ashley Hampsher Holmes Murphy & Assoc - CR PHONE FAX ,, 319-896-7664 r ,. 201 First Street SE, Suite 700 AbbwESS: anampsllexVnolmesmurphy.com INSURERS AFFORDING COVERAGE NAIC# Cedar Rapids, IA 52401 INSURERA:Zurich American Insurance Company 16535 INSURED INSURER B : Travelers Property Casualty Company of 25674 HR Green Pacific, Inc. INSURER CXL SPECIALTY INS CO 37885 1260 Corona Point Court INSURERD; Suite 305 INSURER E: Corona, CA 92879-5013 INSURERF: CCIVFRAC;FS CFRTIFICATF NIIMRFR• 65706021 RFVIQInN NIIMRGR• 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 AODL S4 R POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDJYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL0373096712 01/01/22 01/01/23 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE _xiOCCUR I. GEES T Ea occurRENTEDre ce PAMARENJJ $ 300.000 MED EXP (Any one person) $ 10,000 PERSONAL SADVINJURY $ 2,000,000 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PRO X❑LOC RGENOTHER: JECT PRODUCTS-COMP/OPAGG $ 4,000,000 $ A AUTOMOBILE LIABILITY BAP373096812 01/01/22 01/01/23 COMBINE❑ INGLELim IT a accident $ 2,000,000 BODILYINJURY(Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS Ix BODILY INJURY (Per accident) $ HIRED .X NON -OWNED PROPERTY DAMAGE Pe'a'WICenl $ AUTOS ONLY AUTOS ONLY B X UMBRELLALIAB X OCCUR CUP8S97473322NF 01/01/22 01/01/23 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $ 10, 000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC373096612 01/01/22 01/01/23 X STATUTE OETRH EL EACH ACCIDENT ANYPROPRIETOR/PARTNER/EXECUTIVE -1 $ 1,000,000 OFFICER/MEMBER EXCLUDED? N / A E,L DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E,L DISEASE - POLICY LIMIT $ 1,000,000 C Professional Liability DPR9987508 01/01/22 01/01/23 Per Claim 5,000,000 (Claims Made Coverage) Aggregate 10,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of La Quints. is an Additional Insured on the General Liability on a primary and non-contributory basis as required by written contract with the insured, per policy terms and conditions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of La Quints THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Maria Casillas 78-495 Calls Tampico AUTHORIZED REPRESENTATIVE La Quints, CA 92253 I USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD rolsoncr 65706021 Additional Insured — Automatic — Owners, Lessees Or Contractors 0 ZURICH Policy No. I Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End Producer No. AWL Prem Return Prem. L 3730967-12 01 /01 /2022 1 /01 /2023 01 /01 /2022 37-179-000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: HR GREEN PACIFIC, INC. Address (including ZIP Code): 1260 Corona Point Court Corona, CA 92879 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations or "your work" as included in the "products -completed operations hazard", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the 'occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. U-GL-1175-F CW (04113) Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit" as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D. For the purposes of the coverage provided by this endorsement: 1. The following is added to the Other Insurance Condition of Section IV — Commercial General Liability Conditions: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV —Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same 'occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; 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. All other terms and conditions of this policy remain unchanged. U-GL-1175-F CW (04/13) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission Policy No. WC WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 0 % of the California workers' compensation pre- mium otherwise due on such remuneration. Person or Organization ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. Schedule Job Description WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1