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Insurance Certificates 2022/23 Nichols ConsultingINSURANCE REVIEW Cu �Cu CALIFORNIA RE: SHORT FORM SERVICES AGREEMENT FOR SB 90/STATE MANDATED COST REIMBURSEMENT CLAIM PREPERATION SERVICES WITH NICHOLS CONSULTING. 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: F—]$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: F-1$1,000,000 per occurrence/loss Other: Approved by: Date: List other insurance types such as - molestation, harassment, etc. Laurie McGinley 1 /31 /2023 '°'c"R U CERTIFICATE OF LIABILITY INSURANCE 01/30/20 3YY) 1 DATE 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 poiicy(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 � STATE FARM INSURANCE AGENCY CONTACT NAME: Greg Jun CAICPHONE .916-608-0899IFA C No:916-608-8889 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICH L INSURER A: Slate Farm General Insurance Company 25151 INSURED NICHOLS LOCAL GOVERNMENT INSURER B: State Farm Mutual Automobile Insurance Company 26178 INSURER C: State Farm Fire and CasualtyCompany 26143 CONSULTING LLC 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 OF INSURANCE ADDLSUTYPE B POLICY NUMBER MMIDDmYY MM DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE rx-1 OCCUR Y 90-CJ-W945-5 04102/2022 04/02/2023 EACH OCCURRENCE $ 2.000,000 IS PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE S 4,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY X JPrT PRO- X LOC PRODUCTS - COMP/OP AGG S 4.000,000 g AUTOMOBILE LIABILITY ANY AUTO SCHEDULED AUTOS AUTOS ALL OWNED Ix NON OWNED X HIRED AUTOS AUTOS Y � 225 1177-Dl 9-55K 10/19/2022 04/19/2023 COMBINED SIN LE LIMI Ea accident S BODILY INJURY (Per person) $ 1.000,000 BODILY INJURY (PeraWdent) S1,000,000 PRPERTY DAMAGE (Per accident) S 1,000,000 S UMBRELLA LIAR EXCESS LIAR I OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ DED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORtPARTNER/EXECUTIVE YIN OFFICEIMEMBER EXCLUDED? El (Mandatory in NH) If yes, describe under DrISCRIPTION OF OPERATIONS below N 1 A ❑ WC STATU-IMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT S A Professional Liability-E&O Each Occurrence 3726-708 04119l2022 04/19l2023 2,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INSURED: CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA CA 92293 r`CoTiCfr`n TC uni nco CANCFI I ATION 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 © 1988-2010 CORD03ORPORATION. All rights reservea. ACORD 25 (2010/d5) The ACORD name and logo are registered marks of ACORD 1001585 137643.3 12-21-2010 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 FE-6609 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 Printed in U.S.A. /� o t6 Declaration of Sole Proprietor CF`y OF T�'O DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Nichols Local Government Consulting, LLC (dba "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 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 ftclaratigns shag constitute an addendum to any �id or contracts awarded to January 27, 2023 Date Authorized 1