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PROOF OF INSURANCE (2021) CLOSEDDATE (MMIDDIYYYY) AiC"R" CERTIFICATE OF LIABILITY INSURANCE 08/05/2021 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 CONTACT THIMBLE https://support.thimble.com/ NAME. Verifly Insurance Services, Inc. DBA Thimble Insurance Services PHONE"" FAX 174 West 4th Street, Suite 204 W 49 94 (A/c No) EMAIL support.@thimble.com thimble.com i New York, NY 10014 tlhC(CiP�AwS . ...... � �.'._ . i https://support,thimble.com/ INSURERS) AFFORDING COVERAGE NAIC p INSURER Markel Insnranrp r:mmnanv 38970 INSURED David Howard Combine Academy djhowardO920@gmail.com 90056 COVERAGES CERTIFICATE NUMBER: INSURER D : INSURER E : thimble.com/check-policy 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, a..... I TR TYPE OF INSURANCE ..ADOL'S1)'AR .....,,, .. " , L......, .. POLICY NUMBER ,...... POLICY EFF "�CtLi�CY SAG'+ MMIDD/YYYY MWODfYYYi" .. .. ! LIMITS X COMMERCIAL GENERAL LIABILITY 08/05/2021 09/05/2021 EACH OCCURRENCE ,RENTED s 1,000,000 CLAIMS -MADE X OCCUR I I 2:12 PM 11:59 PM bA kat ro P�,E ryssE�„(Ea nrr�"rre, re) S 10Q,Q0Q „ ,.. PDT PDT' MED EXP (Any one person) $ 5,000 .. A Y Y VFMK-P389AD9KM See note D ...... PERSONAL S AV INJURY s 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: I on expiration _GENERAL AGGREGATE S 1,000,000 �I PRO �l X POLICY JE CT LOC u date below PRODUCTS - COMP/OP AGG S 1 000 00 0 OTHER, s 1 AUTOMOBILE LIABILITY COMBINED SINGLE V. WT S ANY AUTO '.. '.. BODILY INJURY (Per person) S SCHEDULED OWNE INJURY ( ccidenl} S . AUTOS ONLY AUTOS HIRED NON -OWNED ORC ii RTY"DAIVfiA,GL�.,.. S .I, AUTOS ONLY - „,,. AUTOS ONLY '.., -BODILY ...LWet uncosrYrcutk S UMBRELLA LIAB OCCUR EACH OCCURRENCE „ s EXCESS LIAB CLAIMS -MADE AGGREGATE S DED RETENTION $ S WORKERS COMPENSATION PLR OrH- `n T AT IE ,.. �R_ IAND EMPLOYERS' LIABILITY ` "'�" ' " ANY OFFICER/MEM ER/EXCLUDED? ECUTIVE """" NIA. EL EACH ACCIDENT s .�. r Mandato m NH ( ry ) SE EA EMPLOYEE E L DISEASE S _..._. ;Ifyes, describe under (DESCRIPTION OF OPERATIONS below I E,L. DISEASE- POLICY LIMIT , S EACH OCCURRENCE S 1,000,000 2:12 PM 11:59 PM .......... Professional Liability Y Y VFMK-P389AD9KM PDT PDT' AGGREGATE $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) *Please note that the insured has purchased a monthly policy that will automatically extend upon expiration of the policy if the insured pays the appropriate premium. At that time, you will receive a new Certificate of Liability Insurance, evidencing such extension. on form Acord 1 CERTIFICATE HOLDER CANCELLATION 350 Main St El Segundo Ca, 90245 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 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY dj h owa rd 0920„@g m a i Immco m LOC #: 1 CCW? "� AnnITIONAI RFMARKS SCHFnIII F Pane 1 of 1 ..AGENCY NAMED INSURED Verifly Insurance Services, Inc. DBA Thimble Insurance Services David Howard POLICY NUMBER....,_...___...........�,_..�,�............. .......,....._................. Combine Academy VFMK-P389AD9KM djhoward0920@gmail,com CARRIER NAIC CODE 90056 m.EFFECTIVE DATE: 08/05/2021mIT2:12 PM PDT,,......_,.�.��,�,�,�,...�.._�,.�.�.�.� .. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 FORM TITLE: Certificate ofLiabilityInsurance Description of Operations (con't) Products and Completed Operations coverage (VFMK-GL-0203-0919) for policy number VFMK- P389AD9KM until 09/05/2022 11:59 PM PDT ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: VFMK-P389AD9KM COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON SO OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. E-Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability 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 operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured, B. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non - renewal to any Designated Person or Organization shown in the SCHEDULE above at the e-mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declarations. All other terms and conditions remain unchanged, VFMK-GL-2001-0318 ©2018VeriflyInsurance Services, Inc. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc,, with its permission POLICY NUMBER: VFMK-P389AD9KM COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. Information re uired to complete 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 we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 POLICY NUMBER: VFMK-P389AD9KM COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): City Of El Segundo, Its Officers, Officials, employees, agents, volunteers E-Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability 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 operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured, B. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non - renewal to any Designated Person or Organization shown in the SCHEDULE above at the e-mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declarations. All other terms and conditions remain unchanged. VFMK-GL-2001-0318 ©2018 Verifly Insurance Services, Inc. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: VFMK-P389AD9KM COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTEI INSURANCE CE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL 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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: VFMK-P389AD9KM COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City Of El Segundo, Its Officers, Officials, employees, agents, volunteers Information required to complete 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 we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 0 For Roadside Assistance: 800-531 -8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: . usaa.com, . USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem.6-13 50781-0513 02 ... _------_....-------------------.-..-_--_.,..----------------- -- -------------------- ............,....,........ .._...................,.... b a c k CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25941 California Evidence of Financial Responsibility HOWARD Keep this card. IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of o financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, DAVID J HOWARD d impoundment or license suspension. Insurance Company UNITED SERVICES AUTOMOBILE ASSN Policy Number Effective Date 00515 86 35U 7106 2 05/10/21 ehicle Make/Vehicle Identification NuinkrIll LANROVER Expiration Date I Additional copies available at usaa.com 11 /10/21 2 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 For Roadside Assistance: 800-531 -8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: usaa.com, USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem. 6-13 50781 -051 302 -_.---------------------..----........_-___-_----_----------------.------.....---- ------------------------------------------------------- .--- ----------_------- b a c k CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25941 California Evidence of Financial Responsibility ioWARD Keep this card. IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of o financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, DAVID J HOWARD d impoundment or license suspension. Insurance Company UNITED SERVICES AUTOMOBILE ASSN Policy Number Effective Date Expiration Date 00515 86 35U 7106 2 05/10/21 11/10/21 Vehicle Make/Vehicle Identification Number Year FORD 2013 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. Additional copies available at usaa.com CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 For Roadside Assistance: 800-531 -8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: . usaa.com, . USAA's Mobile App, or . By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem.6-13 50781-0513 02 -----------------ax.,a-�----------------------------------------------------- .- _ _...__ _ _.._.._ . -b -a �--k--- _ .-.._ . ,.. _.. CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25941 California Evidence of Financial Responsibility HOWARD Keep this card. IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of o financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, DAVID J HOWARD d impoundment or license suspension. I Insurance Romany UNITED SERVICES AUTOMOBILE ASSN Policy Number Effective Date Expiration Date Additional copies available at usaa.com 00515 86 35U 7106 2 05/10/21 11/10/21 VFORD Make/Vehicle Identific NUM 1 Year 2012 CONTACT US: 210-531-USAA(8722) This policy provides at least the minimum amounts of liability insurance OR 800-531-USAA required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. 9800 Fredericksburg Road, San Antonio, Texas 78288 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. I 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 El 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # I certify that, in the performance of the work set forth in the agreement with the City of El 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 to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant David J Howard Print Name Agreement for: I a4 Dated. Reviewed by: