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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. W4 --a SURAN W. T"t COVERAGE PROMED BY DIPS P01JCV 11*111XI'S YHE COMPANY &Gu6cy MAPIRAM. 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W13 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: ;-` .