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Insurance Certificates 2022/23 Signature SculptureMEMORANDUM DATE: TO: FROM: 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. Authority to execute this agreement is based upon: ___ Approved by City Council on ___________________________________________ ___ City Manager’s signing authority provided under the City’s Purchasing Police [Resolution No. 2019-021] for budget expenditures of $50,000 or less. ___ Department Director’s or Manager’s signing authority provided under the City’s Purchasing Policy [Resolution No. 2019-021] for budget expenditures of $15,000 and $5,000, respectively, or less. Procurement Method (one must apply): ___ Bid ___ RFP ___ RFQ ___ 3 written informal bids ___ Sole Source ___ Select Source ___ Cooperative Procurement Requesting department shall check and attach the items below as appropriate: ___ Agreement payment will be charged to Account No.: _____________________ ___ Agreement term: Start Date ________________ End Date ________________ ___ Amount of Agreement, Amendment, Change Order, etc.: $____________________ REMINDER: Signing authorities listed above are applicable on the aggregate Agreement amount, not individual Amendments or Change Orders! ___ Insurance certificates as required by the Agreement for Risk Manager approval Approved by: ______________________________ Date: _______________ ___ Bonds (originals)as required by the Agreement (Performance, Payment, etc.) ___ Conflict of Interest Form 700 Statement of Economic Interests from Consultant(s) NOTE: Review the “Form 700 Disclosure for Consultants” guidance to determine if a Form 700 is required pursuant FPPC regulation 18701(2) ___ Business License No. __________________; Expires: __________________ ___ Requisition for a Purchase Order has been prepared (Agreements over $5,000) July 26, 2022 Jon McMillen, City Manager Michael Calderon, Community Resources Analyst AGREEMENT FOR CONTRACT SERVICES WITH SIGNATURE SCULPTURE FOR ART MAINTENANCE SERVICES FOR $60,000 PER FISCAL YEAR ✔July 19, 2022 ✔ ✔270-0000-74800 ✔July 1, 2022 June 30, 2025 ✔60,000 (per fiscal year) ✔ Monika Radeva 7/26/2022 ✔LIC-0101046 8/31/2022 ✔ / ACCORD® � 0® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 04/05/2023 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 StateFarm JOHN FORD O 79440 CORPORATE CENTRE DR STE 104 CONTACT Karen Schroeder NAME: PHONE Ext): 760-564-0011 (AA/C, No): 760-564-0221 E-MAILkaren.schroeder.itgu©statefarm.com OOa LA QUINTA, CA 92253 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : State Farm Mutual Automobile Insurance Company 25178 INSURED BRETT FIORE DBA: SAME DAY EXPRESS & SIGNATURE SCULPTURE PO BOX 111 PALM DESERT, CA 92261-0920 INSURER B : INSURER C : INSURER D : INSURER E : 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 INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY ANY AUTO OWNED >/ /\ SCHEDULED AUTOS NON -OWNED AUTOS ONLY Y 214 8782-C24-55 450 1653-D02-55 03/24/2023 04/02/2023 09/24/2023 10/02/2023 COMBINSINGLE LIMIT (Ea accidEDent) $ BODILY INJURY (Per person) $ 1,000,000 BODILY INJURY (Per accident) $ 1 ,000,000 PROPERTY DAMAGE (Per accident) $ 1,000,000 UMBRELLA LIAB EXCESS LIAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured: The City of La Quinta, its officers, officials, employees and agents CERTIFICATE HOLDER CANCELLATION THE CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 6028BU ADDITIONAL INSURED (Prior Notice of Termination) This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. 1. A person or organization shown on the Declarations Page as an Additional Insured is provided Liability Coverage, but only to the extent that person or organization qualifies as an insured as defined in Liability Coverage. 2. An Additional Insured has the same right of recovery under Liability Coverage as if they had not been shown on the Declarations Page as an Additional Insured. 3. If Liability Coverage is changed or terminated as to the interest of the Additional Insured, unless another number of days notice is shown on the Declarations Page, we will provide the Additional Insured: a. 10 days notice of such change or termination if the policy is nonrenewed or the cancellation is for nonpayment of premium; and b. 20 days notice of such change or termination if the cancellation is for any reason other than nonpayment of premium. Page 1 of 1 6028BU ©, Copyright, State Farm Mutual Automobile Insurance Company, 2011 / A� " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/10/2022 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 CONTACT Karen Schroeder NAME: StateFarm JOHN FORD AH/ONE Ext : 760-564-0011 FAX No : 760-564-0221 79440 CORPORATE CENTRE DR STE 104 AODRIess: karen.schroeder.itgu@statefarm.com 0 &O INSURERS AFFORDING COVERAGE NAIC # LA QUINTA, CA 92253 INSURER A: State Farm Mutual Automobile Insurance Company 25178 INSURED INSURER B : INSURER C : BRETT FIORE INSURER D : DBA: SAME DAY EXPRESS & SIGNATURE SCULPTURE INSURER E : PO BOX 111 INSURER F : PALM DESERT, CA 92261-0920 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 SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGES( RENTED CLAIMS -MADE OCCUR ccurrence)$ PREMISES Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ JECTPRO ❑ LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY Y 214 8782-C24-55 09/24/2022 03/24/2023 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 1,000,000 A ANY AUTO OWNED �/ SCHEDULED AUTOS ONLY x AUTOS 450 1653-D02-55 10/02/2022 04/02/2023 BODILY INJURY (Per accident) $ 1,000,000 PROPERTY DAMAGE Per accident $ 1,000,000 HIRED 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 ANY PROPRIETOR/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 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured: The City of La Quinta, its officers, officials, employees and agents CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE CITY OF LA QUINTA ACCORDANCE WITH THE POLICY PROVISIONS. 78495 CALLE TAMPICO AUTHORIZED REPRESENTATIVE LA QUINTA, CA 92253 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 06/23/2022 Desert Cornerstone Insurance Service, Inc. CA License #0F15709 81713 Hwy 111, Ste E Indio CA 92201 Tina Eads (760) 347-7723 (760) 347-7725 tina@desertcornerstoneins.com Same Day Express, LLC, DBA: Dba: Same Day Express; DBA: Signature Sculpture RestorationSignature Sculptures Restoration P.O. Box 111 Palm Desert CA 92261 Century Surety Company 36951 22-23 GL A Y CCP1077458 07/01/2022 07/01/2023 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 Certificate holder is named as additional insured per form CGL1816 0216 when required by a written contract. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 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 ACORD HIRED AUTOS ONLY CGL 1816 0216 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY . ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION, PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization Location(s) of Covered Operations Any person or organization that you are required to add as an additional insured pursuant to a written contract or agreement. Various locations as per written contract with the Named Insured. 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: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to “bodily injury” or “property damage” occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of “your work” out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 3 of 4 CGL 1816 0216 C.The insurance provided for the benefit of the above scheduled additional insured(s) shall be primary and non- contributory, but 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 for the additional insured(s) at the location(s) designated in the Schedule above. D.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits of Insurance and Deductible: 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. All other terms and conditions of this policy remain unchanged. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 4 of 4 MEMORANDUM DATE: TO: FROM: 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. Authority to execute this agreement is based upon: ___ Approved by City Council on ___________________________________________ ___ City Manager’s signing authority provided under the City’s Purchasing Police [Resolution No. 2019-021] for budget expenditures of $50,000 or less. ___ Department Director’s or Manager’s signing authority provided under the City’s Purchasing Policy [Resolution No. 2019-021] for budget expenditures of $15,000 and $5,000, respectively, or less. Procurement Method (one must apply): ___ Bid ___ RFP ___ RFQ ___ 3 written informal bids ___ Sole Source ___ Select Source ___ Cooperative Procurement Requesting department shall check and attach the items below as appropriate: ___ Agreement payment will be charged to Account No.: _____________________ ___ Agreement term: Start Date ________________ End Date ________________ ___ Amount of Agreement, Amendment, Change Order, etc.: $____________________ REMINDER: Signing authorities listed above are applicable on the aggregate Agreement amount, not individual Amendments or Change Orders! ___ Insurance certificates as required by the Agreement for Risk Manager approval Approved by: ______________________________ Date: _______________ ___ Bonds (originals)as required by the Agreement (Performance, Payment, etc.) ___ Conflict of Interest Form 700 Statement of Economic Interests from Consultant(s) NOTE: Review the “Form 700 Disclosure for Consultants” guidance to determine if a Form 700 is required pursuant FPPC regulation 18701(2) ___ Business License No. __________________; Expires: __________________ ___ Requisition for a Purchase Order has been prepared (Agreements over $5,000) July 26, 2022 Jon McMillen, City Manager Michael Calderon, Community Resources Analyst AGREEMENT FOR CONTRACT SERVICES WITH SIGNATURE SCULPTURE FOR ART MAINTENANCE SERVICES FOR $60,000 PER FISCAL YEAR ✔July 19, 2022 ✔ ✔270-0000-74800 ✔July 1, 2022 June 30, 2025 ✔60,000 (per fiscal year) ✔ Monika Radeva 7/26/2022 ✔LIC-0101046 8/31/2022 ✔ 06/23/2022 Desert Cornerstone Insurance Service, Inc. CA License #0F15709 81713 Hwy 111, Ste E Indio CA 92201 Tina Eads (760) 347-7723 (760) 347-7725 tina@desertcornerstoneins.com Same Day Express, LLC, DBA: Dba: Same Day Express; DBA: Signature Sculpture RestorationSignature Sculptures Restoration P.O. Box 111 Palm Desert CA 92261 Century Surety Company 36951 22-23 GL A Y CCP1077458 07/01/2022 07/01/2023 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 Certificate holder is named as additional insured per form CGL1816 0216 when required by a written contract. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 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 ACORD HIRED AUTOS ONLY CGL 1816 0216 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY . ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION, PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization Location(s) of Covered Operations Any person or organization that you are required to add as an additional insured pursuant to a written contract or agreement. Various locations as per written contract with the Named Insured. 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: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to “bodily injury” or “property damage” occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of “your work” out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 3 of 4 CGL 1816 0216 C.The insurance provided for the benefit of the above scheduled additional insured(s) shall be primary and non- contributory, but 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 for the additional insured(s) at the location(s) designated in the Schedule above. D.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits of Insurance and Deductible: 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. All other terms and conditions of this policy remain unchanged. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 4 of 4 06/23/2022 Desert Cornerstone Insurance Service, Inc. CA License #0F15709 81713 Hwy 111, Ste E Indio CA 92201 Tina Eads (760) 347-7723 (760) 347-7725 tina@desertcornerstoneins.com Same Day Express, LLC, DBA: Dba: Same Day Express; DBA: Signature Sculpture RestorationSignature Sculptures Restoration P.O. Box 111 Palm Desert CA 92261 Century Surety Company 36951 22-23 GL A Y CCP1077458 07/01/2022 07/01/2023 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 Certificate holder is named as additional insured per form CGL1816 0216 when required by a written contract. City of La Quinta 78495 Calle Tampico La Quinta CA 92253 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 ACORD HIRED AUTOS ONLY CGL 1816 0216 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY . ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION, PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization Location(s) of Covered Operations Any person or organization that you are required to add as an additional insured pursuant to a written contract or agreement. Various locations as per written contract with the Named Insured. 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: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to “bodily injury” or “property damage” occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of “your work” out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 3 of 4 CGL 1816 0216 C.The insurance provided for the benefit of the above scheduled additional insured(s) shall be primary and non- contributory, but 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 for the additional insured(s) at the location(s) designated in the Schedule above. D.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits of Insurance and Deductible: 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. All other terms and conditions of this policy remain unchanged. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. Page 4 of 4 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) _ 07101/2022 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 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 CONTACT NAME: LUIS E PEREZ PERFECT BALANCE INSURANCE SERVICES, INC. I PHONE _ FAX 73867 FRS❑ WARING DRIVE - INSURER 5) AFFORnING COVERAGE PALM DESERT _ CA 92260 INSURER A: STATE COMPENSATION INSURANCE FUND INSURED SAME DAY EXPRESS LLC INSURER B : DBA: SIGNATURE SCULPTURE _INSURERC: PO BOX 111 INSURERD: PALM DESERT CA 92260 INSURERS: 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 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES ❑ESCRiBED HEREIN IS SUBJECT THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TO ALL THE TERMS, INSR ADDI. SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE R POLICY NUMBER MMlDDNYYYI IMMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY p— DAMq�E TO RENTED PREMISES Ea occurrence CLAIMS -MADE OCCUR $ MED EXP (Any one person) $ PERSONAL & ADV }NJURY 5 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/DP AGG $ POLICY 71 jI'a LOG S AUTOMOBILE LIABILITY j COMBINED SINGLE LIMIT j Ea accident $ ANY AUTO BODILY INJURY (Per Person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) 5 HIRED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE AUTOS S Per accident UMBRELLA LIgB OCCUR EACH OCCURRENCE j S EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION S ! $ WORKERS COMPENSATION WC STATU- DTH- AND EMPLOYERS' LIABILITY YIN X TORY LI TU- _�E&_ A ANY PROPRIETORWARTNEWEXECUTIVE E.L EACH ACCIDENT OFFICEfMEMSER EXCWDED? ❑ NIA 1960687-2022 07l01l2022 07101l2023 _ s 1,goo 0k0 _ (Mandatary in and E.L. DISEASE. - EA EMPLOYE If yes, describe under $ 1,000,000 DESCRIPTION OF ).QFR&J1ONS below E.L. DISEASE -POLICY LIMIT $ 1.000,000 FF DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more s ace is regwired 10 DAY NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM. 30 DAY NOT I�E OF CANCELLATION FOR OTHER THAN OF PREMIUM, ANY AND ALL OPERATIONS BY THE NAMED INSURED ON BEHALF OF THE CERTIFICATE HOLDER. NON-PAYMENT CERTIFICATE HOLDER CANCELLATION CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA ACORD 25 (2010105) 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 CA 92253 LUIS E PEREZs---------Z — �! O 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Clear All ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/14/2022 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 _? JOHN FORD Ge 79440 CORPORATE CENTRE DR STE 104 c� CONTACT Karen Schroeder PHONE 760-564-0011 FAX 760-564-0221 A/C No Ext : A/C No ADDRESS: karenschroeder.itgu@statefarm.com LA QUINTA, CA 92253 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: State Farm Mutual Automobile Insurance Company 25178 INSURED INSURER B : BRETT FIORE INSURER C : DBA: SAME DAY EXPRESS & SIGNATURE SCULPTURE INSURER D : PO BOX 111 INSURER E PALM DESERT, CA 92261-0920 INSURERF: 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 INSD SUER WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED — CLAIMS -MADE OCCUR PREMISES Ea occurrence $ ME EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY _ Y 214 8782-C24-55 03/24/2022 09/24/2022 (CEO, ccidentBINED SINGLE LIMIT $ BODILYINJURY(Perperson) $ 1,000,000 A ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS 4501653-D02-55 04/02/2022 10/02/2022 BODILY INJURY (Per accident) $ 1,000,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident)$ 1,000,000 UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured: The City of La Quinta, its officers, officials, employees and agents CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE CITY OF LA QUINTA ACCORDANCE WITH THE POLICY PROVISIONS. 78495 CALLE TAMPICO AUTHORIZED REPRESENTATIVE LA QUINTA, CA 92253 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016