Loading...
16-0419_KEETON KREITZER CONSULTING_InsuranceWORKERS' COMPENSATION DECLARATION I hereby affirm, under penalty of perjury under the laws of the State of California , as follows (initial one): X I certify that while performing the services required by my agreement with the City of San Juan Capistrano , I shall not employ any person in any manner so as to become subject to the workers ' compensation laws of California. I agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code , I shall immediate ly comply With the provisions of Section 3700 . I have and will maintain workers' compensation insurance as required by Section 3700 of the Labor Code , while serving as an Independent Contractor providing leisure services/programs for the City of San Juan Capistrano. My workers' compensation insurance carrier and policy number are : Carrier _________ _ Policy No. _______ _ (Original to follow) I have and will maintain a certificate of consent to self-insure for workers' compensation , as provided by Section 3700 of the Labor Code, while serving as an Independent contractor providing leisure services/programs for the City of San Juan Capistrano. Failure to secure Workers' Compensation coverage is unlawful , and shall subject an employer to criminal penalties and Civil fines up to $100 ,000 , in addition to the cost of compensation and damages as provided for in Section 3706 of the Labor Code , interest, and attorney fees . Name of Declarant: Keeton K. Kreitzer Business Name: Keeton Kreitzer Consulting Executed this 4th day of April 2016 at _O_r_a_n.....:g:.....e ____ _ (City), California . Signature : ACORD TM CERTIFICATE OF LIABILITY INSURANCE I Date (MM/DD/YR) I 4/5/2016 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 ORAL TER 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 require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Diana Chau SelectSolutions Insurance Services, LLC NAME: PHONE J FAX License# 0127711 INC,No,Extl: 714-361-7700 {NC,No): 855-804-8449 1350 Carlback Avenue EMAIL dianac@ppibselect.com ADDRESS: Walnut Creek, CA 94596 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Travelers Indemnity Co. of CT 25682 Keeton Kreitzer Consulting INSURERS: Continental Casualty Co 20443 5122 Glen Albyn Lane INSURERC: Orange, CA 92869 INSURERD: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER· REVISION NUMBER· THIS IS TO CERTIFY THAT 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER (~3,~g~) (~~~~) LIMITS LTR INSR WVD GENERAL LIABILITY EACH OCCURRENCE $1,000,000 -DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $1,000,000 A -[}Sj OCCUR 6804879L211TCT15 09/01/2015 09/01/2016 CLAIMS-MADE X X MED EXP (Any one person) $10,000 -PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L. AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG $2,000,000 J POLICY IXl PROJECT n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1NCLIN GL (Ea accident) - A ANY AUTO BODILY INJURY (Per person) $ -,-- SCHEDULED ALL OWNED AUTOS AUTOS 6804879L211TCT15 09/01/2015 09/01/2016 BODILY INJURY (Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) -1-- $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ -1--N/A AGGREGATE $ EXCESS LIAB CLAIMS-MADE DED I I RETENTION $ $ WORKERS COMPENSATION I WCSTATU-I I ~~H-I AND EMPLOYERS' LIABil-ITY YIN TORY LIMITS ANY PROPRIE:TORIPARTNER/EXECUT/VE/ D E.l.. EACH ACCIDENT $ OFFICER!MEMBE:R EXCLUDED? N/A N/A (Mandatory In N.H.) E.l.. DISEASE-EA EMPLOYEE $ If yes, descnbe under DESCRIPTION OF E.L. DISEASE -POLICY LIMIT $ OPERATIONS below Per Claim $1,000,000 B PROFESSIONAL LIABILITY EEH254020947 05/06/2015 05/06/2018 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Re: As Per Contract or Agreement on File with the Insured. City of San Juan Capistrano, its officials, officers, employees, agents and City designated volunteers are named as Additional insured on General Liability policy if required by written contract p attached endorsement. Waiver of subrogation applies to General Liability policy if required by written contract per the attached endorsement. The Non-Owned and Hired Auto Liability Limit Is Subject To The General Liability Per Occurrence Limit. The Professional Liability Limits shown represent the Per Claim! Aggregate Limits of Liability. The above policies contain a 30 day notice provision for cancellation/non-renewal. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH City of San Juan Capistrano THE POLICY PROVISIONS. 32400 Paseo Adelanto AUTHORIZED REPRESENTATIVE San Juan Capistrano, CA 92675 ~(f~ ACORD 25 (201 0/05) ©1-8-2010 ACORD CORPORATION. All nghts reserved. The ACORD name and logo are registered marks of ACORD POLICY NO.: 6804879L211TCT15 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to WHO IS AN INSURED (Section II}: Any person or organization that you agree in a "contract or agreement requiring insurance" to Include as an additional insured on this Coverage Part, but only with respect to liability for "bodily injury", "property damage" or "personal injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing operations; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "products-completed operations hazard". Such person or organization does not qualify as an additional insured for "bodily injury", "property damage" or "personal injury" for which that person or organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which coverage as an additional insured specifically is added by another endorsement to this Coverage Part. e. This insurance does not apply to the rendering of or failure to render any "professional services". f. The limits of Insurance afforded to the additional insured shall be the limits which you agreed in that "contract or agreement requiring insurance" to provide for that additional insured, or the limits shown in the Declarations for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF INSURANCE (Section Ill} for this Coverage Part. B. The following is added to Paragraph a. of 4. other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV}: However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis, this insurance is primary to other Insurance that is available to such additional insured which covers such additional insured as a named insured, and we will not share with the other insurance, provided that (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have entered into that "contract or agreement requiring insurance". But this insurance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. c. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV}: We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insurance" with such person or organization entered into by you before, and in effect when, the "bodily CG 03 81 09 07 © 2007 The Travelers Companies, Inc. Page 1 of2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. injury" or "property damage" occurs, or the "personal injury'' offense is committed. D. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal injury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. CG 03 81 09 07 © 2007 The Travelers Companies, Inc. Page2 of2 Includes copyrighted material of Insurance Services Office, Inc., with its permission.