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PROOF OF INSURANCE (2021) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DArEIMMDDlY1 08/25/2021 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(les) 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 NAME: Mass Merchandising K&K Insurance Group, Inc„ r,C,No Ext c 1-800-328-2317 4Aac Nei 1 260 459-5502 1712 Magnavox Way MAIL Fort Wayne IN 46804 ADDAILSSa info@eventinsurance-kk.com RE INSURERS AFFORDING COVERAGE NAIC # INSURED 2001033029 CP# 536 INSURER A: Nationwide Mutual Insurance Company 23787 Sandra Delgado INSURER B: DBA_ Welcome Spanish LLC INSURER C: INSURER D: ......,.,.„.s.�...w,,,,,............................................................................... INSURER E: A Member of the Sports, Leisure & Entertainment RPG INSURER F: COVERAGES CERTIFICATE NUMBER: 2000514301 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MM/DDIYYY MM/DD/YYVVw A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007274100 12/02/20 ...a�"__"._ 12/02/21 EACH OCCURRENCE ............. $1,000,000 CLAIMS-MADEF,.00CUR 12:01 AM 12:01 AM.................................__�. DAMAGE rORENTED $1,000,000 PREMISES (Ea Occurrence) MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $5,000,000 GENERAL AGGREGATE POLICY ❑ PROJECT ❑ LOC PRODUCTS COMP/OPAGG "PROFESSIONAL """""" $1,000,000 IT$1,000,000 OTHER: LIABILITY LEGAL LIAB TO PARTICI PA N T S $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLEL (a accident ANY AUTO BODILY INJURY (Per person) SCHEDULED ............... ._...._�._........��. ..................... OS ONLY AUTOS BODILYRaccident) HIIRNED ED denDAMAG ONLYHAUTOSONLYNON-OWNED er X Not provided while in Hawaii UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIABH CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION N/A '.. PER STATUTE OTHER AND EMPLOYERS' LIABILITY """""-"""........ """"""""""• ANY PROPRIETOR/PARTNER/ Y / N EL. EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E,L DISEASE EA EMPLOYEE If yes, describe under """""""""""""" """"""....... DESCRIPTION OF OPERATIONS below E L, DISEASE -POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Instructor of: Language The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION The City of El Segundo, Its Officers, Officials, Employees, Agents and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Volunteers EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 3501 Main St THE POLICY PROVISIONS. El Segundo, CA 90245 Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. Coverage is only extended to U.S. events and activities. "" NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000007274100 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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) The City of El Segundo, its Officers, Officials, Employees, Agents and Volunteers 3501 Main St El Segundo, CA 90245 Named Insured: Sandra Delgado DBA: Welcome Spanish LLC CP# 536 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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, 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. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 ©Insurance Services Office, Inc., 2012 Page 2 of 2 Cal%mia Piroof of Auto Insurance Card AlOate Northbrook w , PO Box 6605% Dallas, 9'97 Sandra Delgado as This policy meets the requirements of the applicable California financial gasp-nslblllty Iaw(s). POLICY 'NUMBER. 06 307147 EFFECTIVE DATE 09/05/21 EXPIRATION DATE 03 2 This card must be caused in the vehicle at awrimes as evidence of insurance. 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. U I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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 # 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 thosegavlsions gnthe agre went will automatically become void. Signature of Applicant Print Name Sandra Delgado Agreement for: Dated: 11/8/21 Reviewed by: D /21