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PROOF OF INSURANCE (2022) CLOSED40RU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/24/2021 THIS CERTIFICATE IS 1 D AS A MATTER 6P INFORMATOR 6RILY TOW 55WERSNO RIUMP E CERTIFICATE HOLDER. THI 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. IMP RTA T: I the certificate holder is an ODITONAL IREURED, the po icy(les) must have A I NAL INSURED provisions or Be endorsed. 1 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 Merch Underwriting'.. K&K Insurance Group, Inc. NE 888 580 8041 260-459-5995 ARC Na Etas — ARC,No)_............... 1712 Magnavox Way w' Fort Wayne Indiana 46804 AODRESS uuillfo(c f tnesslnsuranoe Ilk com .. CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC # ... ...................... _..... ------------------------------------------------------------------------------------------uu.............�IT. INSURER A: Nationwide MUIUaI Insurance Company u...23787 INSURED ........................................................................ Alyson Campbell INSURER B: DBA: Alyson Campbell .INS_..S.UR..R...ER ....C: ........................................................ . • _. on-7 Redonao tat=—, 7 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INS URERWE: INSURER F: COVERAGES CERTIFICATE NUMBER: W02009319 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 L.TR TYPE OF INSURANCE ADDL INSO WVD POLICY NUMBER MMIDD_ MNIIDO LIMITS A X '.COMMERCIALGENERALLIABILITY X 6BRP074 G0000020600 09/01/2021 09/01/2022 EACH OCCURRENCE $1,000,000 . CLAIMS- 12:01 AM EDT 1Z01 AM AI A ED ............ .................................... - ---. MADE X..,� OCCUR PREMISES ([L 0c Lrrancel -- ......ITITITITITITITITITITITIT$1,000,000 _ MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGO $1,000,000 PRC. POLICY JEC.`r LOC ,PROFESSIONAL ION LIABILITY A�....---.. ..�..- $1,000,000 ._....___W OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY SINGLECOMBINED I ANY AUTO BODILY INJURY (Per person) OWNED SCHEDULED BODILY INJURY (Per accident) .....- IDNON-OWNED ..._ PRUErUAV,.............. ...... ............ ....................................... _. AY A ccetL n_....................................... .................................................................. .. NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB H CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A OTHER EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ Y / N E L EACH ACCIDENT EXECUTIVEOFFICERIMEMBER ........................................................ E.L. DISEASE —EA EMPLOYEE ................................................... EXCLUDED? (Mandatory in NH) I��I EL DISEASE— POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRP00000007420600 09/01/2021 09/01/2022 PRIMARY MEDICAL Li. 12:01 AM EDT 12:01 AM ... ......................................... . .__........... ...-... ....... J EXCESS MEDICAL $SOOO DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certified Instructor of: Aquatic exercise, ZUMBAO Sexual Abuse or Sexual Molestation Liability - $100,000 each occurrence (included above)/$300,000 aggregate (included above) 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, '. t.IK, I IrII:A I t t1ULUtK L.AN"LLA I It.».IN ;ity of El Segundo SHOUL5 7NY OF THE ABOVE BE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IP 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 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000007420600 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 Or anization City of El Segundo 350 Main Street El Segundo, CA 90245 Named Insured: Alyson Campbell DBA: Alyson Campbell 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 State Farm Mutual Automobile Insurance Company PO Box 853919 Richardson, TX 75085-3919 AT2 A-0558 CAMPBELL, ALYSON S Policy Number: 478 2840-B11.75 Policy Period: August 11, 2021 to February 11, 2022 Vehicle: 2014 KIA SOUL Principal Driver: ALYSON S CAMPBELL A Your auto insurance rates are impacted by the mileage your vehicle is driven. To ensure we've priced our insurance coverage accurately based on the number of miles you drive, we obtained valid mileage information for this vehicle through a third party provider and/or from you. Annual mileage was determined using this data and applied. Please contact your State Farm agent with questions within 30 days of your policy's renewal date. Policy Number: 478 2840-Bl 1-75 Prepared July 6, 2021 1004583 AUTO RENEWAL PREMIUM PAID: $553.34 1')0Il10 III IILAY Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number: " " - Your State Farm Agent LORI RICHARD Office: 310-792-9900 Address: 222 AVE DEL NORTE STE 202 REDONDO BEACH, CA 90277-5701 If you have a new or dBerent car, have added any d6mrs orhave moved, please contact your agent. Thank you for choosing State Farm. When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. Page number 1 of 4 143562 202 01-15-2018 M * Mon I offi You mean a lot to us. If you need anything, call State Farm' Agent Lori Richard at 310-792-9900 . TP31 IIEIV°lllbCl III IIIII4FC)lRI ""III"If ON Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please let us know right away. Vehicle Description 2014 KIA SOUL Vehicle Identification Number (VIN) Who principally drives this vehicle? The premium on the expiring policy term was based on 9,500 miles per year. The premium on the renewal policy term was based on 5,900 miles per year. The premium for this renewal was determined using an annual mileage this vehicle is expected to be driven that was developed from information we obtained or was provided by you. The national average is more than 12,000 miles driven annually according to the U.S. Department of Transportation. Please contact us if you expect your annual mileage to change over the next year. II IIIt.1IVIIIIII,R 11C!!OlZWA""IIrIII IIP Assigned Driver(s) The following driver(s) are assigned to the vehicle(s) on this policy. Name ALYSON S CAMPBELL Driving Experience as of August 11, 2021 Principal Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your How is this vehicle normally used? Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and model. In addition, we review the comprehensive, collision, bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. Marital Status premium may be influenced by the information shown for these drivers. COVERAGE IPIII' I JIMITS See yourpolicyforanexplanation ofthese coverages. A Liability W._�.............. .........._.._.._.._....................... -------- —-------- _____� Bodily Injury 50,000/100,000 50,000 $281.89 C Medical Payments 5,000 $20.50 D 500 Deductible Comprehensive $23.15 G 500 Deductible Collision $184.16 H Emergency Road Service $2.45 U Uninsured Motor Vehicle Bodily Injury 50,000/100,000 $37.28 (continued on next page) Policy Number: 478 2840-B11-75 Page number 2 of 4 Prepared July 6, 2021 COVf'''''IIR GEE AND III...II'dl"'rS conf(rmmred U1 Uninsured Motor Vehicle Property Damage $3.91 Total Premium $553.34 If any coverage you carry is changed to give broader protection with no additional premium charge, we will give Iitlntt(tC I I lNT These adjustments have already been applied to your premium. Record California Good Driver you the broader protection without issuing a new policy, starting on the date we adopt the broader protection. 0 Loyalty ✓ Total Discounts $1,191.48 fflIRCI°I AIIit.CI1i11111;S A I'tllli) III')ISC" CI(Ilit'°"II'S Driving Safety Record Rating Plan Your driving safety record, along with other rating factors, determines what you pay for Liability, Medical Payments, Comprehensive, Collision, and Uninsured Motor Vehicle Coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. For every 12 months since the renewal following the occurrence of a chargeable accident or the conviction of a minor violation, the initial assigned Driver Record Level for that chargeable accident or conviction shall be lowered by 1 level. For each 12 month period since the conviction of a major violation, the initial assigned Driver Record Level for that conviction shall be lowered by 2 levels. The Rate Level is increased if there are subsequent chargeable accidents or convictions. Definition of Chargeable Accidents Chargeable accidents for new business are those which resulted in bodily injury or death or in payment(s) by an insurer due to damage to any property in the amount of VIIifllfII 111("IWVIII IIIIII4lFff11 lll'd °f"IIIaIIm If any information on this renewal notice is incomplete or inaccurate, or if you want to confirm the information we have in our records, please contact your agent. For additional more than $1000. For accidents occurring prior to December 11, 2011, an accident shall be chargeable provided it resulted in death or in payment(s) by an insurer due to damage to any property in the amount of more than $750. For applicants without prior insurance at the time of the accident, an accident shall be chargeable provided it resulted in damage to any property in the amount of more than $1000 (more than $750 if the accident occurred prior to December 11, 2011). Chargeable accidents for renewal business are those which resulted in bodily injury or death or State Farm claim payments totaling more than $1000 (more than $750 for accidents occurring prior to December 11, 2011) under property damage liability coverage and collision coverage combined. For more information about the rating plan, please contact your State Farm agent. Superior Driver Rate Level information regarding discounts or coverages, see your State Farm agent or visit statefarm.com®. limpoirtaint Notice Ili egaurdlrmg Your IIPreiimiliiirnn State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors including: Policy Number: 478 2840-Bl 1-75 Prepared July 6, 2021 (continued on next page) Page number 3 of 4 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. 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 Name of Agent Policy Number Expiration Date Phone # 1r 11 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. AI son Campbell 041allyeq-dbyNyseeCamptW1 7/ 21 Y p Date: 2021, 11,17N:1a:50-M'UR Signature of Applicant � Da Print Name Alyson Campbell Agreement far. 1 Z—/ &/Z Dated: Reviewed by.