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PROOF OF INSURANCE (2022) CLOSEDCCOR " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/17/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYD CONFERS NO RIGHTE UP6N THEI I A 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. I P RTANT`: 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 endorsements . PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group, Inc. NNT `") info77actvit c0lubs kk.com 1-260-459-5502 1712 Magnavox Way r�° Exl lAICCN r).` Fort Wayne IN 46804 ADDRESS: @ Y INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Natalie kfOrtlgi INSURER B: ...................m..-----_...................... ,.INSURER C:........��............................................... A Member of the Sports, Leisure & Entertainment RPG INSURER D: -u- INSURER E: INSURERF:....................................................................................---------......... ------ COVERAGES CERTIFICATE NUMBER: W02004954 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 LTRINSD TYPE OF INSURANCE WVD POLICY NUMBER MMIDD POLICYFXP MMII.... �p...............__....��......................................................................................... LIMITS A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007507000 09/17/2021 09/17/2022 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR MADE L ] 12,01 AM EDT 12:01 AM Y� PREMISES Ea Occurrence $1,000,000 MED EXP (Any one person) $5 000 PERSONAL &mADV INJURY....... ..........................$.1,000,000.. GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1000,000 POLICY ECT LOC PROFESSIONAL LIABILITY $1,000,000 OTHER: .._._............ LEGAL LIAB TO PARTICIPANTS ................. ..w..._.�........... $1 ,000,000 A AUTOMOBILE LIABILITY ANY AUTO 6BRPG0000007507000 09/17/2021 12:01 AM EDT 09/17/2022 12:01 AM COMBINED ac SINGLE LIMIT$1,000,000 JtRBODILY (Per person} .......... ..... ........ ......... ------------------------ . ITITITIT OWNED AUTOS SCHEDULED ONLY AUTOS _................ ..a� a BODILY INJURY (Per accident) X HIRED NON -OWNED AUTOS ONLY X AUTOS ONLY Y DAMAGE (Per accident X NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION _..... .........._._._.... WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A OTHER STATUTE Li 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 A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007507000 09/17/2021 09/17/2022 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM ExCEss-----MEDICAL ------------- $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Type of club activities: Art 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. ; A K I It-IL;A I t MUL UIZK t.;ANlLtL LA I IUN' amity of El Segundo SHOULD ANY OF TRE ABME RIBED POLICIES BE CANCELLED BEF RI 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED It D Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. Owner/Lessor of Premises) AUTHORIZED REPRESENTATIVE 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 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRP00000007507000 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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) City of El Segundo 350 Main Street El Segundo, CA 90245 Named Insured: Natalie Strong 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 1 of 1 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 # yl certify that, in the performance of the work set forth in the agreement with the City of El Segundo, i will not ggrKee oy any person in any manner so become subject to the workers' compensation laws of California, and that, wf I shout co su to lie workers' compensation provisions of Labor Code § 3700 1 must immediately comply with th tie agreement will automatically become void. Signature of Appl c 2a t Date I Print Name i Agreement ent for: el A tli-5 `4 C 191 ~ Dated; 11/12/21 Reviewed by: Hank Lu, Risk Manager