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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: