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PROOF OF INSURANCE (2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE 08/26/2021 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). ADMINISTRATOR CONTACT Special Event Deparmicut Hub International Insurance Services, Inc PHONE (925) 609-6500 FAX (925) 609-6550 P.0 Box 4047 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC 0 Concord CA 92424-4047 INSURERA Co0ony llils,urance 0)arnpany 39993 INSURED INSURER 8 Anna Giannotis INSURER C LLos Angeles CA 90245 INSURER F: COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE AND INSURED MEMBER ENDORSEMENT LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE COVERAGE 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 INSURED MEMBER ENDT NUMBER COVERAGE EFFECTIVE/EXPIRATIN DATE LIMITS COMMERCIAL GENERAL LIABILITY 21000158 08/26/2021/ EACH oCCURRENCE j 1,0Q0,000 A CLAIMS -MADE OCCUR DAMAGE TO RENTED 08/26/2022 5,01Q10 1 )00,000 GENERAL. AGGREGATE APPLIES I GENERAL AGGREG s 2.000.000 SEPARATELY TO THE NAMED INSURED -,""I'll, 11 11 11-1 ­­­", I'll ��!'E 11 I'll, I I "I'll", -1 "I'll I --'I'll, I AS PER ATTACHED ENDORSEMENT F"QDUCTS COMPPOPAGG S 2,00000 T1523-0111 LIQUOR LIABILITY PER S 1,000,000 OCCURRENCE (AGGREGATE INCLUDED IN GENERAL LIABILITY AGGREGATE) ........... . ... .. .. . . .. . ........ MASTER POLICY NUMBER: 103 g] 0 193585-00 EFFECTIVE DATE: 202 1 -01 -01 EXPIRATION DATE: 2022-01-01 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD, 101, Additional Remarks Schedule, may be attached if more space Is required) The certificate holder is included as Additional Insured as per endorsement T5409-0118. This insurance is Primary and Non -Contributing as per endorsement T1095-0108. The insurance company waives rights of recovery as per endorsement CG2404-0509. The Insured Member Endorsement cannot be cancelled by the insurance company as per endorsement TI 523-0111 Event Type: Instructor Event Locations: 300 E. Pine Avenue El Segundo CA 90245 El Segundo 350 Main Street ElSeaundo 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 Master Policy Number: 103 gl 0193585-00 Member Endorsement Number: 21000158 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 Additional Insured Persons Or Organization(s El Segundo 350 Main Street El Segundo CA 90245 Information required to co m lete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zations) shown in the Schedule, 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 omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. T5409-0118 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. Member Endorsement Number: 21000158 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 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 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 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IF CAREFULLY. SEPARATION U S - INSURED MEMBERS AND REPORTING I S T Master Policy Number: This endorsement modifies insurance provided under the following: 103 gl 0193585-00 COMMERCIAL GENERAL LIABILITY COVERAGE PART Member Endorsement Number: LIQUOR LIABILITY COVERAGE PART 21000158 A. SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, and COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY, 2. Exclusions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM, and SECTION I — LIQUOR LIABILITY COVERAGE, 2. Exclusions of the LIQUOR LIABILITY COVERAGE FORM are amended and the following added: This insurance does not apply to: Unreported Events "Bodily injury", "property damage", "personal and advertising injury" or "injury" arising out of any "Insured Member(s)" that you have not reported in the Policyholder's Bordereaux, subject to SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Reporting Provisions added in item E. below. However, this provision does not apply in the event of an unintentional error or omission in not reporting an "Insured Member" in the Policyholder's Bordereaux if such "Insured Member" received a Certificate of Insurance and paid the premium prior to the "bodily injury", "property damage" or "personal and advertising injury" or "injury" that resulted in a claim or "suit". B. SECTION II — WHO IS AN INSURED, 1. a. of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY COVERAGE FORMS, is deleted and replaced with the following: a. An individual, you and your spouse are a named insured, but only with respect to your conduct as an "Insured Member" named on the Certificate of Insurance referenced in item C. below. C. SECTION II — WHO IS AN INSURED of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY COVERAGE FORMS is amended and the following added: 4. Any "Insured Member" issued a Certificate of Insurance evidencing coverage under this Master Policy will qualify as a Named Insured. However, for the "Event Information" designated in the Certificate of Insurance: a. COVERAGE A does not apply to "bodily injury" or "property damage" that occurred before the "Event Information" inception date shown in the "Certificate policy period"; and b. COVERAGE B does not apply to "personal and advertising injury" arising out of an offense committed before the "Event Information" inception date shown in the "Certificate policy period"; and c. LIQUOR LIABILITY COVERAGE does not apply to "injury" that occurred before the "Event Information" inception date shown in the "Certificate policy period". D. SECTION IV — COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY CONDITIONS, 7. Separation Of Insureds is deleted and replaced with the following: 7. Separation Of Insureds This insurance is provided under a Master Policy and applies: a. as if each "Insured Member' shown on a Certificate of Insurance were the only Named Insured; and T1523-0111 Page 1 of 3 b. separately to each "Insured Member" against whom claim is made or "suit" is brought. The Limits of Insurance shown in the Certificate of Insurance issued to the "Insured Member" will apply separately to each "Insured Member" to which this insurance applies. All terms and conditions of this Master Policy are the terms and conditions applicable to the "Insured Member" during the "Certificate policy period". If the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member" is after to the expiration date of the Master Policy, coverage will cease upon the expiration date of the "Certificate policy period." In no event will coverage for the "Insured Member" extend beyond twelve (12) months after the expiration of the Master Policy. If the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member" is prior to the expiration, termination or cancellation date of the Master Policy, coverage will cease upon the expiration date of the "Certificate policy period." If this Master Policy is terminated or cancelled prior to the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member", coverage for the "Insured Member" will continue under the terms and conditions of the Master Policy until the expiration of the "Certificate policy period." In no event will coverage for the "Insured Member" extend beyond twelve (12) months after the termination or cancellation of the Master Policy. E. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS and SECTION IV —LIQUOR LIABILITY CONDITIONS are amended and the following added: Reporting Provisions a. The premium charged at the inception of each policy year is an advance premium. Upon our receipt of your complete Policyholder's Bordereaux at the end of each "reporting period", an endorsement will be issued by us for any adjustment in premium because of "Insured Member(s)" you added or deleted in the Policyholder's Bordereaux. b. Premium Reporting: (1) You must file a Policyholder's Bordereaux with us each "reporting period" and at Expiration, in accordance with this Reporting Provision, showing separately each "Insured Member" to be covered. In addition to the information required by the Policyholder's Bordereaux, you must include a copy of the Certificate of Insurance issued evidencing the "Insured Member's" coverage provided by this Master Policy. (2) You may not correct an inaccurate Policyholder's Bordereaux after a claim or "suit" has occurred. c. Failure to Submit a Policyholder's Bordereaux: Coverage only applies to: (1) "Insured Member(s)" shown in the Policyholder's Bordereaux you filed with us prior to the "bodily injury", "property damage", "personal and advertising injury" or "injury" that resulted in a claim or "suit", or, (2) "Insured Member(s)" shown on reports or Certificates of Insurance that were on file with HUB International Insurance Services, Inc. prior to the "bodily injury", "property damage" or "personal and advertising injury" or "injury" that resulted in a claim or "suit". However, paragraph c. does not apply in the event of an unintentional error or omission in not reporting an "Insured Member" in the Policyholder's Bordereaux except if such "Insured Member" received a Certificate of Insurance and paid the premium prior to the "bodily injury", "property damage", "personal and advertising injury" or "injury" that resulted in a claim or "suit". T1523-0111 Page 2 of 3 F. SECTION IV — COMMERCIAL GENERAL LIABILITY and SECTION IV — LIQUOR LIABILITY CONDITIONS, 5. Premium Audit, are deleted and replaced with the following: 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. If the policy is cancelled, to determine any premium refund or additional premium due, we may elect to use an earned premium computed by an audit or pro rata or less than pro rata calculation of the advanced premium or minimum premium. Paragraph 5. of.A. Cancellation of the Common Policy Conditions is amended accordingly. c. The first Named Insured must keep records of the information we need for premium computation, and send us copies at such times as we may request. G. SECTION V — DEFINITIONS is amended and the following added: 1. "Insured Member" means: a. a member of the First Named Insured shown in the Declarations and named as the Event Holder on a Certificate of Insurance issued evidencing the "Insured Member's" coverage under this Master Policy; and b. evidenced on the Policyholder's Bordereaux filed with the company. Throughout this policy the words "you" and "your" refer to the "Insured Member" as a Named Insured under this Master Policy. 2. "Event Information" means the event and the area or location where the event is being conducted provided the event is designated on the Certificate of Insurance issued to that "Insured Member" and Policyholder's Bordereaux filed with the company. 3. "Certificate policy period" means the period of time coverage under this Master Policy will apply for the "Insured Member" indicated on the Certificate of Insurance issued to that "Insured Member". 4. "Reporting period" means the period of time shown below that you must record and file with us a Policyholder's Bordereaux on all changes to the issued Certificates of Insurance, including copies of the Certificates of Insurance issued evidencing the "Insured Member's" coverage under this Master Policy. The "reporting period" is: a. each calendar month starting at policy inception, and then each consequential month, and b. ninety (90) days from the date of non -renewal or the date of cancellation if this policy is cancelled prior to policy expiration. Each monthly Policyholder's Bordereaux shall include Certificates of Insurance issued within the previous three (3) calendar months that were not previously reported to us. All references to LIQUOR LIABILITY in this endorsement only apply if a LIQUOR LIABILITY COVERAGE PART is attached to this policy. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. T1523-0111 Page 3 of 3 Master Policy Number: 103 gl 019356W 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: All persons or organizations as requested by written contract with the Named Insured.. 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 (A Stock Insurance Company) SAA0 9800 Fredericksburg Road - San Antonio, Texas 78288 CALIFORNIA AUTO POLICY - RENEWAL DECLARATIONS ATTACH TO PREVI US P LICY Named Insured and Address ANNA G LUNA D cr% tion of Vehicles VEH YEAR[ TRADE NAME MODEL BODY TYPE 051651 FORD ESCAPE 4D 061021 NISSAN QUEST GLE MINIVAN RENEWAL OF State 105 06 Vero POLICY NUMBER hk 00854 54 07C 7101 2 POLICY PERIOD: (12:01 A.M. standard time) EFFECTIVE AUG 07 2021 TO FEEL 07 2022 OPERATORS 03 4000 1000 IDENTIFICATION NUMBER VEH USE* WORK/scIloOL bllgpm 0nIs SYM pne P r p Week �P 'P -he Vehicle(s) described herein is principally garaged at the above address unless otherwise stated.-, rr�audsm�woea— ur ..1.! s. P 9"Iw• ids VEH 05 LOS ANGELES CA 90034-5401 VYLE706 L'S AN'GELES CA 90034-5401 Is Cro pro Icy ve es thosecoverages w ere a premium is shown a ow. T e limits shown max roe reduced by policy provisions and may not be combined regardless of the number of vehiclA� fnr whit-.h nromilnr" is lictiewti11nimc cnosa+i ir* lllw, �vu+ ^riv-A ei— -k..s ;- +6;- 1. . COVERAGES LIMITS OF LIABILITY VEH DD 6 VEH ODC VEH i VEH(] ("ACV" MEANS ACTUAL CASH VALUE) I)ED PRMONTEMIUM E PREMIUM D=DEo I PREMIUM D=DED I PREMIUM AMOUNT fiu'i I' T $ MOUN71 $ +DUN' $ TART A - LIABILITY � BODILY INJURY EA PER $ 50,00 EA ACC $ 100,OOC 114.71 67.66 PROPERTY DAMAGE EA ACC $ 50,00C 126.12 67.88 'ART B - MEDICAL PAYMENTS EA PER $ 50,OOC 18.51 10.65 EXTENDED BENEFITS WAGE EARNER DISAB $2,000 PER 0-DAY PERIOD ESSENTIAL SVCS DISAB $45 WK 3.24 3.24 'ART C - UNINSURED MOTORISTS BODILY INJURY EA PER $ 50,00 EA ACC $ 100,OOC 27.88 19.9 WAIVER OF COLL DEDUCTIBLE .79 .56 'ART D - PHYSICAL DAMAGE COVERAGE COMPREHENSIVE LOSS ACV LESS D 200 21.01D 200 17.68 COLLISION LOSS ACV LESS D 250 120.96D 250 63.47 RENTAL REIMBURSEMENT STANDARD CLASS 16.90 16.9 TOWING AND LABOR 8.53' 8.53 EHICLE TOTAL PREMIUM 458.65 276.47 TOTAL PREMIUM - SEE FOLLOWING PAGE(S) NDORSEMENTS: ADDED 08-07-21 - NONE EMAIN IN EFFECT(REFER TO PREVIOUS POLICY)- RSGPCW(01) 5100CA(02) NFORMATION FORMS: CADS(05) 40CA 01 13580(03) 5000 C 05-12 we nave causeo hiss policy to be Signed by our President and Secr'e on this date JULY 8, 2021 Karen Morris, Secrelary o, James Syring, P+esdent 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: (U 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 Name of Agent Policy Number Expiration Date 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 lziaa Aurrriza&rs Date 9/8/2021 Anna Giannotis Print Name Agreement for: ` Dated: 10/25/21 Reviewed by: J