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PROOF OF INSURANCE (2020 - 2020) CLOSEDJ MARVI N-01 'TDD
CERTIFICATE OF LIABILITY INSURANCE DATE 9/18/20(MM/DD (MM/DD/YYYY) 9
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.
.. ..............................................................w.....................................
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).
qpy..............
PRODUCER
RATeCTNancy Garcia
Teggner-Miller Insurance Brokers AX
200'1 Wilshire Blvd, S'uiite 101 i N , Ext); (310) 526-1774 (A, No);
Santa Monica, CA 90403 ADDRkSS, nancy@tmilb,com
INSURER(S) AFFORDING COVERAGE NAIC 0
INSURER A: Penn -Star Insurance I"omWy 10673
INSURED INSURER B:
J. Marvin Campbell INSURER C:
dba: The Gym Mechanic
4248 Vinton Ave INSURER D'
Culver City, CA 90232 INSURER E:
INSURER F :'
COVERAGES CERTIFICATE NUMBER REVISION NUMBER: _._ITITITITITITIT__.
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 ADDL ptl i POLICY EFF POLICY EXP
LTR TYPE OF.INSURANCE D � POLICY NUMBER IMMIDONY'YY'I IMMIDD(YYYYtl LIMITS
A ,i( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
CLAIMS -MADE X OCCURCPV0022944 9/15/2019 9/15/2020 DAMAGE TO RENTED 100,000
x PREMISES (Ea cutmnce) S
GEN'L AGGREGATE LIMIT APPLIES PER.
POLICY LOC
OTHE°R.
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIR. NON -OWNED
AU' S ONLY AUTOS ONLY
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS -MADE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE
q�FFICE,R/MEMBER EXCLUDED?
andatory in NH)
It yyes„ describe under
DESC'RIPT'ION OF OPERATIONS below
MED EXP (Ary one person) S 61000
PERSONAL & ADV INJURY $ 110001,000
GENERAL. AGGREGATE $1 2,000,000
PRODUCTS • COMP4'P AGG S 2,0'00,000
..._........_..._. $
COMBINED SINGLE LIMIT'
('Ea acmderrt) S
BODILY INJURY (Per person) S
BODILY INJURY (Per accident), $
PROPERTY AMAGE
(Per acciden., $
..................................................
$
EACH OCCURRENCE $
AGGREGATE $
. $
07
PER
ERH
N / A E EACH ACCIDENT $
E L DISEASE - EA EMPLOYEE $
E L DISEASE - POLICY' LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ti I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EI Segundo Police Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 p ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St.
EI Segundo, CA 90245 _ .... ._..........................................................................
AUTHORIZED REPRESENTATIVE
/4-
ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
EPA -1746 (1012015)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS WHEN
REQUIRED IN CONTRACT OR AGREEMENT (OTHER
THAN CONSTRUCTION)
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 person or
organization when you and such person or
organization have agreed in writing in a contract,
agreement, or permit, that such person or
organization be added as an additional insured on
your policy. Such 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:
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 or in connection with your
premises rented to you.
However, the insurance afforded to such
additional insured:
1. Only applies to the extent permitted by law;
2. Will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured; and
3. Only applies to "occurrences" or coverages not
otherwise excluded under this policy.
B. Status as an additional insured for the person or
organization to which this endorsement applies:
1. Commences during the policy period and
after such written contract, written agreement
or written permit has been executed; and
2. Ends when:
a. Your ongoing operations for that additional
insured are completed; or
b. The lease of premises expires, or
c. This policy is cancelled or otherwise
terminates,
whichever occurs first.
C. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to:
1. "Bodily injury", "property damage" or "personal
and advertising injury" arising out of the
rendering of, or the failure to render, any
professional architectural, engineering or
surveying services, including:
a. The preparing, approving, or failing to
prepare or approve, maps, shop drawings,
opinions, reports, surveys, field orders,
change orders or drawings and
specifications; or
b. Supervisory, inspection, architectural or
engineering activities.
This exclusion applies even if the claims
against any insured allege negligence or other
wrongdoing in the supervision, hiring,
employment, training or monitoring of others
by that insured, if the "occurrence" which
caused the "bodily injury" or "property
damage", or the offense which caused the
"personal and advertising injury", involved the
rendering of or the failure to render any
professional architectural, engineering or
surveying services.
2. "Bodily injury" or "property damage" occurring
after:
a. 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
b. 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.
EPA -1746 (1012015) Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2
with its permission.
D. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
The most we will pay on behalf of the additional
insured is the amount of insurance:
1. Required by the contract or agreement you
have entered into with the additional insured;
or
2. Available under the applicable Limits of
Insurance shown in the Declarations,
whichever is less.
This endorsement will not increase the applicable
Limits of Insurance shown in the Declarations.
Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., EPA -1746 (10/2015)
with its permission.
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CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
affirm under penalty of perjury under the laws of California one of the following declarations:
(__) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of EI Segundo.
Policy No.
(_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier
Name of Agent
Policy Number Expiration Date
Phone #
(es) I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject Io, "he workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with tl)o,;,e provt'srcy7�dr,'Ne agreement will automatically become void.
Signature of Applicant + ..�.� r'° Date
10106/17
.._._...._............................ .............................
Agreement for: GYM MECHANIC
Dated _A/
Reviewed by: ;-` .