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PROOF OF INSURANCE (2022 - 2023) CLOSEDAC"ems CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/16/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAT10N ONLY AND CONFERS NO RIGR79 UPON THE CERTIMATE 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. INFO A . I the certificate holder is an ADDITIONAL INSURED, the policy()es) must have ADDITIONAL INSURED provisions or Be en orsed. 11 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 ON1'ACT NAME: MM — Fitness Instructor/Personal Trainer K&K Insurance Group, Inc. Alc No, Ext): 800 506 4856 (A/C , No): 1-260-459-5502 1712 Magnavox Way fi: .. Fort Wayne IN 46804 ADDRESSs Info@fitnessinsurance-kk.com CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC # ... ....................................._......... ._,�.................�... .......�,...�..,..,.............m..m.._...W_................. INSURED..w......�.m..... .,....-..... INSURER A: Markel Insurance Company 38970 Tiffany Spadola INSURER e: - �.............. ... _............... -..... - ....... ............. -........ El Segundo, CA 90245 wsuRERc:._.---.._— ............................... ._. ...... A Member of the Sports, Leisure & Entertainment RPG INSURER D:....................... ............ INSURER E: ,............................... , _ _ _ _........ ... �,....... ..... m. ...... ,. .. .. INSURER F: COVERAGES CERTIFICATE NUMBER: W02197700 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 POLICY NUMBER LTN INSD WV0 POLICY F LIMITS IMM/DD/YYYY IT mMMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY X MlRPG000000O016600 06/01/2022 06/01/2023 EACH OCCURRENCE $1,000,000 CLAIMS- .... �.�.� -. 00CUR 12:01 AM EDT 12:01 AM S tUt UT•°i' "RfFN7,ETY ".m.,...................................._....... .... .,.,.,..... MADE _. PRFMISES,EraC.7orurr�ncF $1^000,000 ................ MED EXP (Any one person) $5,000 PFEzsoNa,L& Ar.}v INJu....._..._m....................................----........._-... RY $1,000,000 ._.._................................_..................�,.................,,,..wwww. m....................................................$5,000,000... GENERAL AGGRE: GFi ........ GENT.. AGGREGATE LIMIT APPLIES PER: PROL)UCT�S��-���������COIUIPLOP•AGC.;T —........•wm.,.�..................�1 ,000,000�� X POLJTC f LOC PROFESSIONAL .Y OTHIF.R R5.7[C1[TJUI 7 ... ...° _ $1,000,000 IPANTS AUTOMOBILE LIABILITY COMBINED MNGLE' P.J Ni „(Ea accident..............._............................................................._...._...._....... ) ... .. . ANY AUTO BODILY INJURY (Per person) . OWNEDAUi"CSS SCHEDULED BODILY )II Y I N JURY ONLY AUTOS nt) (Per r accident) •' .._. HIRED .. ,. NON -OWNED i�h'�ilF"I�Y'%1HNiAf-. ... .................................. .., ,., AUTOS ONLY AUTOS ONLY (Per accident) NOT PROVIDE::.D WI ilLE IN I-MWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE _.,�.. ._..... EXCESS LIAR CI AIMS -MADE. LJ ,,,,,,,,,,,,,,,,,,,,,,,,m„mm,,,,m----m._____ AGGREGATE DEC [— RETENTION .. WORKERS COMPENSATION AND NIA RE OTHER EMPLOYERS' LIABILITY STA'TU'TE. ANY PROPRIETOR/PARTNER/ YIN E I... EACH ACCIDE:r.N1 EXECUTIVE OFFICERIMEMBER ..E,L..... �..FA.EMPL.OYE.E..... � .................................................................................... EXCLUDED? (Mandatory in NH) DISEASE E.L.. DISEASE —POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS MARY MEDICAL. L_LFX (";E:r.t•:>S ME::.Dl(.1AL.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Non -certified Instructor of: Children's fitness programs 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, it's officers, employees, agents, and volunteers SHOULD ANY OF B E E I8ED 11561_05leS §E UA0ELLED THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 401 Sheldon street ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 (Owner/Lessor of Premises) 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: MlRPG000000O016600 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) The City of El Segundo, it's officers, employees, agents, and volunteers 401 sheldon street El Segundo, CA 90245 Named Insured: Tiffany Spadola 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 Important informati2n, Here are your Policy Identification Cards We've provided two (2) cards for each vehicle on your policy. Need a&itignal ID car The GEICO Mobile app is the quickest way to get additional ID cards. You can also send a copy of your ID cards to anyone that needs them right from the app! Evidence of Insurance Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a, fine of up to: $1,000 for the first time; $2,000 for additional times, Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Cut Along the Dotted Line ........... California Evidence of Liability Insurance GEIC0. GEICO General Insurance Company P.O. Box 509090 - San Diego, CA 92150-9090 NAIL Code', 2022 TOYOTA HIGHLANDER 35882 Vehicle ID N Policy Number Effective Date Expiration Date 4326-72-51-18 04/19/22 10/19/22 Named Insured(s) I Addiress Tillany Teruko Spadola El Segundo CA 90245-3276 FOr 0 HERE FOLD HERE FOLD I IEFIE FOLD HERE: FOLD IIERE 0LJ) 1--iERE.'. 2022 TOYOTA HIGHLANDER Additional Drivers 11TIFFANYT SPADOLA EL SEGUNDO CA 90245-3276 Cut Along the Dotted Line California Evidence of Liability Insurance GEIM. GEICO General Insurance Company P.O. Box 509090 - San Diego, CA 92150-9090 NAIL Code! 2022 TOYOTA HIGHLANDER 35882 Vehicle ID No Policy Number Effective Date Expiration Date 4326-72-51-18 04/19/22 10/19/22 Named Insured(s) Address l Tiffany Teruko Spadola El Segowundo CA 90245.3276 FM D HERE F C% 1) HEIRE r ULD rIERE FOLD HERE uFOLD i HAIIE F 01, 11a Mffr�oJ� 2022 TOYOTA HIGHLANDER Additional Drivers ih-01-00voT age pmvilded by this PoIlCY M00% the rdNmum rect0amerAs W 50OWn 1:6056 or 16WO 5of the Cglovnia Vehicle Code, mr1atinum Rab%ty lAds PrMlodbed by law. rho rave(age pnwidecl by this Policy greets the Cm nlfoum; TOCILOrements 0 "tliori t6056 or 16M0,5 of the CAlHornla V4rNdo Code, rnlnimum mbftj WrMs prescrlbed by law. 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 Name of Agent Policy Number Expiration Date Phone # X1I 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 Signature of,,, Nignt ho ��Ao � greement will automatically become void.Date �� immediately comply with Print Name Agreement for:1-AA,(1\v1'3�\ Dated: Review