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Insurance Certificates 2022/23 Kiley & AssociatesRE: INSURANCE REVIEW eiCadadift Kiley & Associates, LLC Agreement for Federal Lobbyist Services [ .1[ II I]RNI.1 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 3/14/2023 enter ACCORD issue date Commercial General Liability Insurance: $1,000,000 per occurrence/$2,000,000 aggregate OR $10,000,000 per occurrence/$11,000,000 aggregate Additional Insured Endorsement naming City of La Quinta Primary and Non -Contributory Endorsement Automobile Liability: $1,000,000 for hired/non-owned autos only (firm is in Washington, DC) Workers Compensation: (Firm has zero employees, see included statement) 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: Other: $1,000,000 per occurrence/loss Approved by: Date: List other insurance types such as - molestation, harassment, etc. 78495 Calle Tampico I La quinfa, California 9M3 1166.TU.76B6 I www.laquinfaca.goy ACORD® CERTIFICATE OF LIABILITY INSURANCE 44...------ DATE (MM/DDIYYYY) 03/14/2023 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 Hiscox Inc. 520 Madison Avenue 32nd Floor New York, New York 10022 CONTACT NAME: PHONE FAX (A/C No Est): (888) 202-3007 (A/C No): IL ADDRESS: contact@hiscox.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Hiscox Insurance Company Inc 10200 INSURED Kiley & Associates 636 North Carolina Ave Southeast Washington D.C., DC 20003 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 VI/VD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y P100.084.749.3 03/14/2023 03/14/2024 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE RENTE PREMISESO(Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PECOT- PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ S/T Gen. Agg. $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOSAUTOS HIRED AUTOS X SCHEDULED NON OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ CGL HNOA Limit (oar occurrence) $ 1,000,000 UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (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 $ A A Cyber and Data Risk Professional Liability Y Y P101.637.035.1 P100.083.724.3 03/14/2023 03/14/2023 03/14/2024 03/14/2024 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of La Quinta its Mayor, Counsel , officers, Agents, Employees and Volunteers are additional insured. CERTIFICATE HOLDER CANCELLATION 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 HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: P100.084.749.3 Kiley & Associates 7 02/04/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. Name of Additional Insured Person(s) or Organization(s): CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: P100.084.749.3 Kiley & Associates 15 02/04/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy, pro- vided: 1. you have agreed in a written contract or agreement to add such additional insured to a policy providing the type of coverage af- forded by this policy; and 2. you have agreed in a written contract or agreement with such additional insured that this insurance would be primary and would not seek contribution from any other insur- ance available to the additional insured. Name of Additional Insured Person(s) or Organization(s): CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1 Insurance Services Office, Inc., with its permission To whom it may concern, I, Gregory T. Kiley, am the sole proprietor and owner of Kiley & Associates, LLC based in Washington, DC. I carry NO workers compensation as my entity has NO employees. Per Washington, DC law, I am only required to maintain workers compensation insurance if I have one (1) or more employees. From the DC Government web page: District of Columbia law requires every business with one or more employees to carry workers' compensation insurance. Sole proprietors and independent contractors do not need to carry workers' compensation insurance for themselves. V/R, Gregory T. Kiley Kiley & Associates, LLC 636 North Carolina Ave SE Washington, DC 20003 (202) 544-6897 gkiley@kileyassociates.org Aim High Forrn (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification F Go to wvvw.irs.govfFnrmW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Gregory Thomas Kiley \.1' 2 Business name/disregarded entity name, if different from above Kiley to Associates LLC 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the foIlowing seven boxes_ ■ Individual/sole proprietor or single -member LLC ❑ C Corporation ❑ S Corporation LI Partnershp Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) . . Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check LLC if tile LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for US federal tax purposes. Otherwise, a single-onemb r LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner, Other (see instructions) OP 5 Address (number, street, and apt. or suite no.) See instructions. 636 North Carolina Ave SE 6 City, state, and ZIP code Washington, DC 0 0 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) 4 Exemptions (codes apply only to certain entities, not individuals; see instruction on page 3): 410 Exempt payee code (if any) Exemption from FATFATCA reporting code (if any) (Applies to accountsnia n &r r Ott do the US) Requesters name and address (optional) Enter your TIN in the appropriate box. The TIN provided must match the name given line 1 to avoid backup withholding. For individuals, this is generally your socialsecurity number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). if you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Certification Social security number EMT or Employer identification number a 0 2 3 2 4 Linder penalties of perjury, I certify that: I. The number shown on this form is my correct taxpayer identification number (or I am raiti n for a number to be issued to me); and 2. I and not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the internal Revenue Service (IRS) that I amsubject to backup withholding as a result of a failure to report all interest or dividends, or (C) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am . . citizen or other U.S. person (defined below); and 4. The FATFATCA code(s) entered on this form (if any) indicating that l am exempt from FATFATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IFS that you are currently subject to backup withholding because you have failed to report all interest n d dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA)1 and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. ti Sign Signature of Here j u_. person Iv- ti General Instructions Section references once are to the Internal Revenue Code unless otherwise noted. Future developments.. For the latest information about developments related to Form VV-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIi) which may be your sci l security number (SSN), individual taxpayer identification number (1TIN), adoption taxpayer identification number (TI ), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form I 0 - I T (interest earned or paid) (12 • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 10 _ I (various types of income, prizes, awards, or gross proceeds) • Form 10 - B (stock or mutual fund sales and certain other transactions by brokers) Form 10 - (proceeds from real estate transactions) • Form 10 - (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1 -E (student loan interest), I 098-T {tuition) • Form 1099- (canceled debt) • Form 10 - (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (incLuding a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10- 01 )