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PROOF OF INSURANCE (2022 - 2022) CLOSEDDATEQMIYCR CERTIFICATE F LIABILITY INSURANCE 11(0 9/2021 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). PRODUCER CONTACT NAME: MASS MerchandisingPHONE _ _ K&K Insurance Group, Inc. (A/C, No. Exl): 1 800-328-2317 �� � 1-260-459-5502 1712 Magnavox Way E-MAIL __. " " Fort Wayne IN 46804 ADDRESS: info@eventinsurance-kk.com CUSTOMER ID: INSURERS AFFORDING COVERAGE NAIC.. INSURED 2000115087 CP# 701 INSURER A: Nationwide Mutual Insurance Company 23787 Wanda Borgerding INSURER B: . _................................... DBA: Musical Fun For Tots INSURER C: 401 Sheldon St ....................... ....... INSURER D: El Segundo, CA 90245 INSURER E:................... ................ ............ __.._............................. � A Member of the Sports, Leisure & Entertainment RPG--.........._ _........... ... INSURER F: COVERAGES CERTIFICATE NUMBER: 2000524155 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/DD/YYY MM/DD/YYYY A ..........�.. ......... ..... ..... X COMMERCIAL GENERAL LIABILITY ..... X ......__ 6BRPG0000007507400 10/26/21 10/26/22 ........ EACH OCCURRENCE .............. - $1,000,000 CLAIMS -MADE 1._X I OCCUR 12:01 AM 12:01 AM P FM SESOEa Occurrence} $1,000,000 '.. MED EXP (Any one persanj $5,000 . .0 PERSONAL LADY INJURY WWWWWWWnnnn $1,000,000 GEN'LAGGREGATELIMIT APPLIES GENERAL AGGREGATE 0X $5,000,00 POLICY PROJECT LOC ..mm. „ PRODUCTS COMP/OP a ....m.,Www.mmw. WmmWm..w$1,000,000 OTHER: PROFESSIONAL_ LIABILITY $1 LEGAL LIAR TO PARTICIP ANTS . .000,000 ............................$.1,000,000..p AUTOMOBILE LIABILITY COMBlNED SINGi. E I fMIT (Ea ac. iden0 BODILY INJURY (Per person) ANY AUTO OWNED SCHEDULED ......_.._ ............................................... AUTOS ONLY AUTOS H BODILY INJURY (Per accident) HIRED NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X Not provided while in Hawaii U BREL OCCUR LIA6 H EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS MADE DIED RETENTION WORKERS COMPENSATION N/A JPERSTATUTE OTHER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N '.. E.L. 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 it more space is required) Instructor of: Instrumental music 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. JUtH I Im IUA I "4 KLUtt1 k;ANL4cL LA I IUN City of El Segundo 401 Sheldon St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH El Segundo, CA 90245 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE (9 1988-2015 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: 6BRPG0000007507400 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 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. SCHEDULE 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 A14 K114 AMED INSURED VANDA B BORGERDING DDITIONAL DRIVER(S) 1 mYna„flwtu fl,pLOWtl�C•,f G�! iwtt{ TO REPORT A CLAIM, please Calk fSOOI 503,3724 For occe t :o ROADSIDE AS$fSTmCE tONl.y, plensa vaall taOrA 519-647B Thi, da_,rrlrncaa co^arAPnes wr�tlt CVC $1 ri0$5 or S1650O.5 kIA1Cti 27553 55 W. rmpeno�4lrgnn }a1bhP��,A QN21 LIE COVERAGE PROVIDED BY'I'IIIS POLICY ANIEE'I'S THE YV NINIUAI LIABILITY LIMITS PRESCRIBED BY LAW II? YOU HAVE AN ACCI'al, 'I' Notify the police intmedrmely. ti YEAR MAKE VEHICLE IDENTIFICATION NUMBER tl. 2014 KIA minimi r NAMED INSURED t r WANDA B BORGERDING ADDITIONAL DFINEM51 I i p I t I tl I k 1 A 1 u TO REPORT A CLAIM, palaaaa Call 1800) 503.3724 I' For occemo t0 ROA DSOE ASS11STANCE ONLY, p4irrarr c:Yil8866a °ai9-6478 1 This mauronce romohta. •avi-lo CVC Stb0a0 or $16900.15 ItWC,e 27553 0 t I r E sss W. 14li•49NMIh4hP &-ZA 92.121 " r THE COVERAGE PROVIDED BY THIS POLICY AIEETS THE NIINIAIUM LIABILITY LIMITS PRESCRIBED BY LAW IF YOU HAVE AN ACCIDENT Notify [lie pnlice inmIediataly. Capture the names. addresses, telephone numbers. driver license mnnbets i 01j)tule the mantes. addresser, telephone numbers, dlivei license numbers and license Plare numbers of zilf peons involved and or witne."e, and hcen--!Niue numbers nI ;LEI P,et-s n s involved and of wltnes,Sei, � Note anv damage to ocher vehicles- Note stay d;trnngc to niter vehicles, t Do 1101 admit farilt. Do not discuss d1e accident with anyone except your Dn not admit GIu IL Do WA discuss the accident wld, anyone except Your a agent, Mere,Iry ol: [fie l'xdil 'a- agent- Mercury oi• the po itar. 1 Immediately report alf claims to Mercury al (800) SM-3724. Immediately report all claims to Mercuryal (800) 503.3724. Make photo; if poc5iblc, rev- 09A 3 i 'Cake photos if possible. rev- 09/ I3 a I ( o MERCURY AOA INSURANCE,,, IDENTIFICATION CARDS YOUR NEW AUTOMOBILE IDENTIFICATION CARDS ARE ATTACHED. KEEP ONE CARD IN YOUR MOTOR VEHICLE WHILE IN OPERATION. LL IMERC£.RY MERCUR EINSURLANCESU vµ - � �E- mmcnuFORMERCURY CALIFORNIA 'I OF mm _ INSURANCE i �m _ _ _ _ LIABILITY INSURANCE -- Y INSURANCE - IN NSU ANCE COMPANY ; COMPANYA 1 AGE7JCY: BICHLIdEIER rN5 SVCS INC 13101 3768952 D AGEPICY aICHLhaEIER INS SUES INCI1310I 37G 8852 @ ICY NUMBER 01 07 150084433 EFFECTIVE ✓3r EXPIRATION DATES p POLICY NUMBER I EFFECTIVE &EXPIRATION DATES t 02/26/2022 08/26/2022 ° 0401 07 150084433 02/26/2022 08/26/2022 R MAKE 16 LEXUS VEHICLE IDENTIFICATION NUMBER YEAR MAKE VEHICLE tDENTIF'IC:AT'MN NUMBER AED INSURED 1NDA B BORGERDING 2016 NAMED INSUREDXUS I WANDA B BORGERDING , r IITIONAL DRIVERISI I ADDITIONAL. DRIVER(S) n u r q TO REPORT A CLAIM, Plosav call (80D) 03-3724 1 TO REPORT A CLAIM„ please call (8001 503.3724 r av'cmrns ro ROADSIDE AS&SrANCEONLY, pleanart call I,8601 919.6478 I For mccmao to R+OAOSIOE ASsiSTANcE ONLY. plewe caN 1I356i 519-6478 is iraxl,ilcy at rOM011ee with CVC S 16056 rat S 16500.5 NAIC# 27563 j This in5uxorw v comti,sq% with CVC S 16o66 er S16500.5 NAIC# 27553 t qqp (911 n hnl tlorc A R toIIrt In halt a 7l 5ss W. Fnlpciin p�l x v, ra 1. C.A 92821 sss W, Impenaf ihLhIsO. gyMo. CA 92831 E COVERAGE PROVIDED BY THIS POLICY MEETS TIIE T1IE COVERAGE PROVIDED BY THIS POLICY MEETS THE QYIMUNI LIABILITY LIAUTS PRESCRIBED BY LAW A INIAIUM LIABILITY LIb1ITS PRESCRIBED BY LAW 91 YOU HAVE AN ACCIDENT oGfy Elie police immediately. aPtute the names, Addrassex, telephone numbers. driver €icense members id Ikenwe plate nuanl, Fra of all persons utvolvzd anal and svjurj s, ote any damage to other vehicles. o not admit fault, Do nr,t discuss the accident with anyone except your vent. Mercury or the poke. ice. nmediarely report all claims to Mercury at (800) 503-3724. Ike photos if possible. rev. 09113 IF YOU HAVE AN ACCIDEN'F Notify the police immediately. r• Capture die names, addresses, telephone numbers. driver license numbers and license Pirtle numbers of all persons involved and of witnesses. • Note any damage to oiler vehicles. • Do not admit fault. Do not discuss the accident with anyone except your agent- Mercury or dla police, x Intmedia[ely report all chinas to Mercury at (800) 503-3724, . Take photos if possible. rev.09113 ZP 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 # ElI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not Onbloy 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 themearviskons or the a erne, will automatically become void. �. x ' Signature ofAppli ant _ l �m� Date Print Name v .��t_ '1,. Agreement for: k Dated: _ ......®.... _ Reviewed by: