Loading...
PROOF OF INSURANCE (2022) CLOSEDDATE (MM/DD/YYYY) A CERTIFICATE OF LIABILITY INSURANCE 08/10/2021 PRODUCER Maguire Insurance Agency, Inc FWI 1 Bala Pla Ste 100 Bala Cynwyd, PA 19004-1401 610,617.7900 INSURED Jerry Larson COVERAGES THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE ....................................... _____� INSURER A: Philadelphia Indemnity Insurance i .......................,........................................................._.....�... INSURER B: ...................................................................... INSURER C: INSU,RE.R..�.'........................._...................... INSURER E: 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 CERIFICATION 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ........._m__.m...... ........ �. .................. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) LIMITS A X GENERAL LIABILITY PHPK2313020-000 08/11/2021 08/11/2022 EACH OCCURENCE $2,000,000 .. ­75T COMMERCIAL GENERAL LIABILITY NTED PRIGMMES EaRanaurre2S $100,000 CLAIMS MADE �OCCUR Ix ,!ED EXP (Any one person) $2,SOOPROFESSIONAL LIABILITY PERSONAL &ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $4,000,000 X POLICY 71 PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (EA accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY— EA ACCIDENT '.. ANYAUTO OTHER THAN EA ACC AUTO ONLY: AGG �w. EXCESS / UMBRELLA LIABILITY EACH OCCURENCE - ..... ... OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLE RETENTION WORkC1TCO7PrR9XMR AND EMPLOYERS"LIABILITY YIN TORY LIMITS uu ER ER/M£N1Bl�RR Xd"RI.4MR3ELL,� EXECUTIVE a ANY j i OPF�pI. F Y __. E1. EACH ACCIDENT (Mandatory in NH) EL, DISEASE — EA AMPLOYEE G4yats ml'euFebeunder SPEiCNAI. PROVISIONS below E,L, DISEASE— POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS It is understood and agreed that the following entity is added as an additional insured but only with respect(s) to the operations of the named insured except that liability resulting from the additional insured's s ole negligence, l CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE City of El Segundo THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE 350 Main St. CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR El Segundo, CA 90245- LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) PI-FW-009 (06/11) THIS ENDORSEMENT CHANGES THE POLICE'. PLEASE READ IT CAREFULLY Blanket Additional Insured Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION II — WHO IS AN INSURED is amended to include the following as an additional insured, but only with respect to liability arising out of your operations, and in accordance with a required Certificate of Insurance: 1. Managers, Owners or Lessors of the Premises Leased, Rented, or Loaned to You, but only with respect to that part of the premises leased, rented or loaned to you subject to the following additional exclusions: This insurance does not apply to: a. Any "occurrence" which takes place after you cease to be a tenant in that premises; b. Structural alterations, new construction or demolition operations performed by or on behalf of the manager, owner or lessor of the premises; c. Any design defect or structural maintenance of the premises or loss caused by a premises defect. 2. Lessor of Leased Equipment, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s) subject to the following additional exclusions: This insurance does not apply to: Any "occurrence" which takes place after the equipment lease expires. 3. Sponsors, but only with respect to their liability as a sponsor to you. 4. Co -Promoters, but only with respect to their liability as a co —promoter to you 5. Subcontractors 6. Grantor of Franchise, but only with respect to their liability as grantor of franchise to you. With respect to any additional insured covered under this policy, this insurance does not apply to the sole negligence of such additional insured. Page 1 of 1 PI-FW-002 (04/16) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FITNESS AND WELLNESS LIABILITY INSURANCE EXCLUSIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following exclusions are added to Paragraph 2. Exclusions of SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY; and Paragraph 2. Exclusions of SECTION I — COVERAGES, COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY: 2. Exclusions This insurance does not apply to: a. Services Furnished by Health Care Providers (1) "Bodily injury," "property damage" or "personal and advertising injury" based upon or arising out of, in whole or in part, the rendering of or failure to render: (a) Medical, surgical, dental, x-ray, or nursing service, treatment, advice or instruction, or the related furnishing of food or beverages; (b) Any health or therapeutic service, treatment, advice or instruction; or (c) Any service, treatment, advice or instruction in chemical skin enhancement, laser hair removal or replacement. (2) The furnishing or dispensing of drugs or medical, dental or surgical supplies or appliances; or (3) The handling or treatment of dead bodies, including autopsies, organ donation or other procedures. This exclusion does not apply to the rendering of first aid. Paragraph 2.a. (1)(b) above does not apply to a licensed physical therapist providing any health or therapeutic service, treatment, advice or instruction on behalf of the Named Insured. b. Vitamins, Supplements and Steroids (1) "Bodily injury," "property damage" or "personal and advertising injury" based upon or arising out of, in whole or in part, the production, testing or manufacture of vitamins, minerals, herbal supplements, medicinal supplements or nutritional supplements. (2) 'Bodily injury," "property damage" and "personal and advertising injury" based upon or arising out of, in whole or in part, the production, recommendation, selling, testing, promotion, solicitation, or manufacture of steroids. PI-FW-002 (04/16) Page 1 of 2 PI-FW-002 (04/16) c. Improper Fees, Dues and Expenses "Bodily injury," "property damage" and "personal and advertising injury" based upon or arising out of, in whole or in part, improper fees, dues, and expenses incurred or charged by an insured. d. Communicable Disease (1) "Bodily injury," "property damage" or "personal and advertising injury" arising out of any "communicable disease," including but not limited to the following: (a) Acquired Immune Deficiency Syndrome (AIDS); (b) Human Immunodeficiency Virus (HIV); or (c) Hepatitis. (2) This exclusion applies even if such damages arise or are alleged to arise as a result of the insureds' negligent hiring, placement, training, supervision, act, error or omission or alleged sexual and/or physical abuse. (3) For purposes of this exclusion, "communicable disease" means an infectious disease transmittable from person to person by direct contact with an affected person or that person's discharges or body fluids. e. Fungi or Bacteria (1) "Bodily injury," "property damage" or "personal and advertising injury" caused directly or indirectly by the actual, alleged or threatened inhalation of, ingestion of, contact with, exposure to, existence of, or presence of any: (a) "Fungi," "spores," or bacteria; or (b) Substance, vapor or gas produced by or arising out of any "fungi," "spores" or bacteria. (2) Loss, costs or expenses arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, remediating or disposing of, or in any way responding to, or assessing the effects of, "fungi," "spores" or bacteria, by any insured or by any other person or entity. (3) For the purposes of this exclusion, the following definitions are added: (a) "Fungi" means any type or form of fungus, including mold or mildew and any mycotoxins, "spores," scents or byproducts produced or released by "fungi." (b) "Spores" means reproductive bodies produced by or arising out of "fungi." This exclusion does not apply to any "fungi," "spores" or bacteria that are on, or are contained in, an edible good or edible product intended for human or animal consumption. PI-FW-002 (04/16) Page 2 of 2 PI-FW-003 (01/07) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FITNESS AND WELLNESS LIABILITY INSURANCE EXTENSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to Paragraph 1. Insuring Agreement of SECTION I - COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: "Bodily injury" or "property damage" arising out of the rendering of or failure to render "professional training services" shall be deemed to be caused by an "occurrence." B. For the purpose of determining the Limits of Insurance for the coverage provided by this endorsement, any act or omission together with all related acts or omissions in the furnishing of these "professional training services" to any one person will be considered one "occurrence." C. For purposes of this endorsement, "professional training services" means any service, advice, or instruction relating to physical fitness. Page 1 of 1 PI-FW-004 (04/16) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. INDEPENDENT CONTRACTORS PROVIDING PROFESSIONAL TRAINING SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II —WHO IS AN INSURED, Paragraph 2. is amended to include the following: Any individual, other than an "employee," "volunteer worker" or "temporary worker," providing "professional training services" on behalf of the Named Insured. An individual's status as an insured under this endorsement ends when his or her services on behalf of the Named Insured are completed. B. SECTION I — COVERAGES, Paragraph 2. Exclusions, is amended to include the following additional exclusions: This insurance does not apply to: a. "Bodily injury," "property damage" or "personal and advertising injury" arising out of services provided on behalf of any person or organization other than the Named Insured. b. "Bodily injury," or "property damage" occurring after all "professional training services" performed on behalf of the Named Insured have been completed. c. Any claim by an independent contractor who had a relationship with the Named Insured at the time of the alleged injury, regardless of whether that independent contractor was acting in his or her capacity as an independent contractor at the time of the injury. d. To any claim which is initiated, alleged, or caused to be brought about by any insured covered by this policy against any other insured covered by this policy. C. For purposes of this endorsement, "professional training services" means any service, advice or instructions relating to physical fitness. PI-FW-004 (04/16) Page 1 of 1 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 CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25968 50781 -051302 ___b_a_c-k- California Evidence of Financial Responsibility JERRY F LARSON 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, d impoundment or license suspension. JERRY F LARSON 1 Insurance Company USAA CASUALTY INSURANCE COMPANY Policy Number Effective Date Expiration Date 01073 86 99C 7101 7 1 09/02/21 03/02/22 e Year 2004 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 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 self4nsure 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 # 1 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 Califomia, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must Signature ly Applicant vmsmor the agreement will automatically become void. immediately comply with th m J 116 31iaz ! Date Print Name Agreement for: a 11-9-21 Dated: Reviewed by: