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Insurance Certificates 2023/24 PAX Fitness Repairs, LLCit RE: INSURANCE REVIEW Cv idK.rCv CALIFORNIA PAX Fitness Repair, LLC Updated COI, Auto Liability, Additional Insured & Primary and Noncontributory Endorsement documents. 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 6/28/23 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: Approved by: Date: List other insurance types such as - molestation, harassment, etc. 7B495 Calle Tampico 1 La Unto, California 92253 1160.m./0001 www.laquinfaca.gov / A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 06/28/2023 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 Palm Desert Insurance Agency 73241 Highway 111 Suite 1-B Palm Desert CA 92260 CONTACT Kevin Glenn NAME: (HCCONE , EXt): (760) 341-2345 FAX No): (760) 341-0865 E-MAIL kevin©palmdesertinsurance.net ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Scottsdale Insurance Company INSURED PAX Fitness Repair, LLC. 114 Romanza Ln Palm Desert CA 92211 INSURER B : California Automobile Insurance Co. 38342 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: CL2362801584 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. LTRINSR TYPE OF INSURANCE NS ADDL UBR INVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y CPS7813393 07/01/2023 07/01/2024 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO PREMISES (Ea occE ence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PRO PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY )/ /• N/ /• SCHEDULED AUTOS NON -OWNED AUTOS ONLY BA040000053563 07/01/2023 07/01/2024 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CXS4003286 07/01/2023 07/01/2024 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED RETENTION $ $ 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) The City if La Quinta is named as additional insured and coverage is primary and non-contributory with respect to the general liability policy per endorsement #GLS-150s (7-06) CERTIFICATE HOLDER CANCELLATION City of La Quinta 78450 La Fonda La Quinta I 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 ,frjk SCOTTSDALE INSURANCE COMPANY ENDORSEMENT N. kTTncHeoroAND FORMING A PART OF POLICY HLlA19ER ENDORSEPAENT EFFECTIVE DATE 02:01 A.M. STANDARD TINIEj Na3aE 0 IN 5u RED AGENT Ho. CPS 7813393 07/01/2023 I ?P.X FITNESS REPAIR.. LLC. oio68 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following; COMM ERCIAL GENERAL LIABILITY COVERAGE PART With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional in- sured any person or organization whom you are required to add as an additional insured on this policy under a written conlract, written agreement or written permit which must be: a. Currently in effect or becoming effective during the term of the policy; and b. Executed prior to the "bodily injury," "property damage," or "personal and advertising injury." The insurance provided to these additional insureds is lim- ited as Follow; 1. That 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 a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these additional insureds, the following exclusions are added to item 2. Exclusions of SECTION !— COVERAGES: This insurance does not apply to "bodily injury," "property damage" or 'personal and advertising injury" occurring after; a. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion of the covered operations has been com- pleted; or b. That portion of your work" out of which the in- jury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written contract, written agreement or written permit or in the Decla- rations for this policy, whichever is fess_ These lim- its of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declara- tions for this policy. 4. Coverage is not provided for "bodily injury," "property damage," or "personal and advertising injury" arising out of the sole rtegligence of the additional insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property damage," or "personal and advertising injury' arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: Includes copyrighted material of ISO Properties, Inc., with its permission. CGopyrighi, 150 Properties. Inc„ 211)04 GLS-150s (7.06) Page 1 of 2 a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engi- neering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance avail- able to the additional insured whether primary, ex- cess, contingent or on any other basis unless a written contract specifically requires that this insur- ance be primary. When this insurance is excess, we will have no du- ty under SECTION I —COVERAGES to defend the additional insured against any "suit" if any other in- surer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of 15o Properties. Inc.. with its permission. Copyright, ISO Properties. Inc., 2004 GLS-150s (7-06) Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 20 01 1219 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 LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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 provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 1219 0 Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER' CPS 7813393 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER F TRANSFER FEF F RIGHTS OF RECOVERY Y AGAINST OTHERS TO US (WAIVER F SUBROGATION) This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): ANY PER$ON OR ORGANIZATION WITH WHOM THE Ii$LP.t HA$ AGREED TO WAIVE RIGHTS OF RECOVERY, PROVIDED SUCH AGREEMENT IS MADE IN WRITING AND PRIOR TO THE LOSS. UNITED STATES Information required to comphete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the persons) or organization{s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organizations) shown in the Schedule above. CG24041219 Insurance Services Office, Inc., 201a Page 1 of 1 Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to PAY •F1TN t—s S eePA-(e , "--r, as follows: I am the authorized representative of PA-X FITrNc—s s Kket 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 EAC F r,,im S tZePAt 2_ 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 pAX Ft 7h1ers 1W2i_1,- 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 declarations shall constitute an addendum to any bid or contracts awarded to Q/A-X F tTrl C-s s fZ,epP +t e_ Date Auth iz d epresentative 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. ACKNOWLEDGMENT WSA(initial) 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 one year. (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 such stop orders. WL (initial) I 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' Compensation Laws of California. (initial) I understand that California Labor Code § 3700 et seq. requires employers to provide 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 insurance because it has no employees. %,JLJn,__(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 of California regarding workers' compensation insurance. LA,k(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 16i-f , (n day of GLJ Ae— 2023 at LA-Q V(1l 4T-- , California Signat Declarant L!,IG 61(650v3 Print N me of Declarant PTAI- x F nvi� ss iZ6 P1,94W- Print Name of Company