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PROOF OF INSURANCE (2023) CLOSEDDATE CERTIFICATE OF LIABILITY INSURANCE 04/27/2022 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 ED 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). Special p i Department ADMINISTRATOR C r _.._.. ecial Event ..., ........... Hub International Insurance Services, Inc PHONE (925) 609-6500 FAx (925) 609-6550 P.O Box 4047 E-MAIL snecialeventahubintemational.com Concord CA 92424-4047 INSURER A: INSURED �, INSURER B p Kim Wood 631 W Mariposa Ave = INSURER E El Segundo CA 90245 INSURERF: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE AND INSURED MEMBER ENDORSEMENT LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE COVERAGE 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 ........ _ ..,.... .........., pNSR TYPE OF INSURANCE INSURED MEMBER ENDT NUMBER COVERAGE EFFECTIVE/EXPIRATIN DATE LIMITS COMMERCIAL GENERAL LIABILITY 22001565 06/13/2022/ �.- $,,..,1,000,000 EACH OCCURRENCE P MA E T ea ...e� `� CLAIMS -MADE OCCUR O RENTED $ 1 000.000 � � 06/13/2023 i_ t�� �G��rea�a ,.. [..... r GENERAL AGGREGATE APPLIES SEPARATELY TO THE NAMED INSURED AS PER ATTACHED ENDORSEMENT T1523-0111 LIQUOR LIABILITY PER s N/A OCCURRENCE (AGGREGATE INCLUDED IN J GENERAL LIABILITY AGGREGATE) MASTER POLICY NUMBER: 103 GL O193585-01 EFFECTIVE DATE: 2022-01-01 EXPIRATION DATE: 2022-12-31 12:01 A . Standard Time at your Mailin,g Address,..... DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) The certificate holder is included as Additional Insured as per endorsement T5409-0118. This insurance is Primary and Non -Contributing as per endorsement T1095-0108. The insurance company waives rights of recovery as per endorsement CG2404-0509. The Insured Member Endorsement cannot be cancelled by the insurance company as per endorsement T1523-0111.. Event Type: Instructor Event Locations: 300 E Pine Ave City of El Segundo E1Segundo CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 631 West Mariposa Avenue AUTHORIZED REPRESENTATIVE E1Segundo , CA 90245�� Master Policy Number: 103 GL 0193585-01 Member Endorsement Number: 22001565 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and C- 0 Cr co W w V CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 Master Policy Number: 103 GL 0193585-01 Member Endorsement Number: 22001565 COMMERCIAL GENERAL LIABILITY CG 24 "05 09 A.F., dMM IY. 1! kvA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: As required by written contract with the Named Insured that is executed by the parties to the contract prior to the commencement of work that is called for in the contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV— Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. C- 0 Cr 6 w w w V CG 24 04 05 09 C Insurance Services Office, Inc., 2008 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IF CAREFULLY. SEPARATION IO OF INSUREDS - INSURED MEMBERS AND REPORTING ENDORSEMENT SEMENT" Master Policy Number: This endorsement modifies insurance provided under the following: 103 GL 0193585-01 COMMERCIAL GENERAL LIABILITY COVERAGE PART Member Endorsement Number: LIQUOR LIABILITY COVERAGE PART 22001565 A. SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, and COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY, 2. Exclusions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM, and SECTION I — LIQUOR LIABILITY COVERAGE, 2. Exclusions of the LIQUOR LIABILITY COVERAGE FORM are amended and the following added: This insurance does not apply to: Unreported Events "Bodily injury", "property damage", "personal and advertising injury" or "injury" arising out of any "Insured Member(s)" that you have not reported in the Policyholder's Bordereaux, subject to SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Reporting Provisions added in item E. below. However, this provision does not apply in the event of an unintentional error or omission in not reporting an "Insured Member" in the Policyholder's Bordereaux if such "Insured Member" received a Certificate of Insurance and paid the premium prior to the "bodily injury", "property damage" or "personal and advertising injury" or "injury" that resulted in a claim or "suit". B. SECTION II — WHO IS AN INSURED, 1. a. of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY COVERAGE FORMS, is deleted and replaced with the following: a. An individual, you and your spouse are a named insured, but only with respect to your conduct as an "Insured Member" named on the Certificate of Insurance referenced in item C. below. C. SECTION II — WHO IS AN INSURED of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY COVERAGE FORMS is amended and the following added: 4. Any "Insured Member" issued a Certificate of Insurance evidencing coverage under this Master Policy will qualify as a Named Insured. However, for the "Event Information" designated in the Certificate of Insurance: a. COVERAGE A does not apply to "bodily injury" or "property damage" that occurred before the "Event Information" inception date shown in the "Certificate policy period"; and b. COVERAGE B does not apply to "personal and advertising injury" arising out of an offense committed before the "Event Information" inception date shown in the "Certificate policy period"; and c. LIQUOR LIABILITY COVERAGE does not apply to "injury" that occurred before the "Event Information" inception date shown in the "Certificate policy period". D. SECTION IV — COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY CONDITIONS, 7. Separation Of Insureds is deleted and replaced with the following: 7. Separation Of Insureds This insurance is provided under a Master Policy and applies: a. as if each "Insured Member" shown on a Certificate of Insurance were the only Named Insured; and T1523-0111 Page 1 of 3 L- 0 co W W V v C- 0 v 6 w b. separately to each "Insured Member" against whom claim is made or "suit" is brought. w The Limits of Insurance shown in the Certificate of Insurance issued to the "Insured Member" will apply separately to each "Insured Member" to which this insurance applies. All terms and conditions of this Master Policy are the terms and conditions applicable to the "Insured Member" during the "Certificate policy period". If the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member" is after to the expiration date of the Master Policy, coverage will cease upon the expiration date of the "Certificate policy period." In no event will coverage for the "Insured Member" extend beyond twelve (12) months after the expiration of the Master Policy. If the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member" is prior to the expiration, termination or cancellation date of the Master Policy, coverage will cease upon the expiration date of the "Certificate policy period." If this Master Policy is terminated or cancelled prior to the expiration date of the "Certificate policy period" shown on the Certificate of Insurance issued to the "Insured Member", coverage for the "Insured Member" will continue under the terms and conditions of the Master Policy until the expiration of the "Certificate policy period." In no event will coverage for the "Insured Member" extend beyond twelve (12) months after the termination or cancellation of the Master Policy. E. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS and SECTION IV —LIQUOR LIABILITY CONDITIONS are amended and the following added: Reporting Provisions a. The premium charged at the inception of each policy year is an advance premium. Upon our receipt of your complete Policyholder's Bordereaux at the end of each "reporting period", an endorsement will be issued by us for any adjustment in premium because of "Insured Member(s)" you added or deleted in the Policyholder's Bordereaux. b. Premium Reporting: (1) You must file a Policyholder's Bordereaux with us each "reporting period" and at Expiration, in accordance with this Reporting Provision, showing separately each "Insured Member" to be covered. In addition to the information required by the Policyholder's Bordereaux, you must include a copy of the Certificate of Insurance issued evidencing the "Insured Member's" coverage provided by this Master Policy. (2) You may not correct an inaccurate Policyholder's Bordereaux after a claim or "suit" has occurred. c. Failure to Submit a Policyholder's Bordereaux: Coverage only applies to: (1) "Insured Member(s)" shown in the Policyholder's Bordereaux you filed with us prior to the "bodily injury", "property damage", "personal and advertising injury" or "injury" that resulted in a claim or "suit", or, (2) "Insured Member(s)" shown on reports or Certificates of Insurance that were on file with HUB International Insurance Services, Inc. prior to the "bodily injury", "property damage" or "personal and advertising injury" or "injury" that resulted in a claim or "suit". However, paragraph c. does not apply in the event of an unintentional error or omission in not reporting an "Insured Member" in the Policyholder's Bordereaux except if such "Insured Member" received a Certificate of Insurance and paid the premium prior to the "bodily injury", "property damage", "personal and advertising injury" or "injury" that resulted in a claim or "suit". T1523-0111 Page 2 of 3 C_ 0 Cr w F. SECTION IV — COMMERCIAL GENERAL LIABILITY and SECTION IV — LIQUOR LIABILITY co CONDITIONS, 5. Premium Audit, are deleted and replaced with the following: -4 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. If the policy is cancelled, to determine any premium refund or additional premium due, we may elect to use an earned premium computed by an audit or pro rata or less than pro rata calculation of the advanced premium or minimum premium. Paragraph 5. of A. Cancellation of the Common Policy Conditions is amended accordingly. c. The first Named Insured must keep records of the information we need for premium computation, and send us copies at such times as we may request. G. SECTION V — DEFINITIONS is amended and the following added: 1. "Insured Member" means: a. a member of the First Named Insured shown in the Declarations and named as the Event Holder on a Certificate of Insurance issued evidencing the "Insured Member's" coverage under this Master Policy; and b. evidenced on the Policyholder's Bordereaux filed with the company. Throughout this policy the words "you" and "your" refer to the "Insured Member" as a Named Insured under this Master Policy. 2. "Event Information" means the event and the area or location where the event is being conducted provided the event is designated on the Certificate of Insurance issued to that "Insured Member" and Policyholder's Bordereaux filed with the company. 3. "Certificate policy period" means the period of time coverage under this Master Policy will apply for the "Insured Member" indicated on the Certificate of Insurance issued to that "Insured Member". 4. "Reporting period" means the period of time shown below that you must record and file with us a Policyholder's Bordereaux on all changes to the issued Certificates of Insurance, including copies of the Certificates of Insurance issued evidencing the "Insured Member's" coverage under this Master Policy. The "reporting period" is: a. each calendar month starting at policy inception, and then each consequential month, and b. ninety (90) days from the date of non -renewal or the date of cancellation if this policy is cancelled prior to policy expiration. Each monthly Policyholder's Bordereaux shall include Certificates of Insurance issued within the previous three (3) calendar months that were not previously reported to us. All references to LIQUOR LIABILITY in this endorsement only apply if a LIQUOR LIABILITY COVERAGE PART is attached to this policy. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. T1523-0111 Page 3 of 3 Master Policy Number: 103 GL 0193585-01 Member Endorsement Number: 22001565 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 631 West Mariposa Avenue E1Segundo CA 90245 II Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11 — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zations) 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 omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. C_ 0 Cr w w w V v T5409-0118 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. 103 GL 019358SLOI O a IMPORTANT NOTICE: 1. The insurance policy that you have purchased is being issued by an insurer that is not licensed by the State of California. These companies are called "nonadmitted" or "surplus line" insurers. 2. The insurer is not subject to the financial solvency regulation and enforcement that apply to California licensed insurers. 3. The insurer does not participate in any of the insurance guarantee funds created by California law. Therefore, these funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. 4. The insurer should be licensed either as a foreign insurer in another state in the United States or as a non -United States (alien) insurer. You should ask questions of your insurance agent, broker, or "surplus line" broker or contact the California Department of Insurance at the toll -free number 1-800-927-4357 or internet website w,v-*iv.insurance.ca.gov. Ask whether or not the insurer is licensed as a foreign or non -United States (alien) insurer and for additional information about the insurer. You may also visit the NAIC's internet website at wwiv.naic.org. The NAIC—the National Association of Insurance Commissioners —is the regulatory support organization created and governed by the chief insurance regulators in the United States, 5. Foreign insurers should be licensed by a state in the United States and you may contact that state's department of insurance to obtain more information about that insurer. You can find a link to each state from this NAIL internet website: https:/Inaic.org/state—'%veb—map.htnL 6. For non -United States (alien) insurers, the insurer shouldbe licensed by a country outside of the United States and should be on W co W V V D-2-0120 Page 1 of 2 103 GL 0193585`01 0 v w CO the NAIC's International Insurers Department (1:11) listing of approved nonadmitted non United States insurers. Ask your agent, broker, or "surplus line" broker to obtain more information about that insurer. 7. California maintains a "List of Approved Surplus Line Insurers (LASLI)." Ask your agent or broker if the insurer is on that list, or view that list at the internet website of the California Department of :insurance: vwiv.insurance.ca.govl0i-consumers/120-company/0i- lasli/lasli.cfnL 8. If you, as the applicant, required that the insurance policy you have purchased be effective immediately, either because existing coverage was going to lapse within two business days or because you were required to have coverage within two business days, and you did not receive this disclosure form and a request for your signature until after coverage became effective, you have the right to cancel this police within five days of receiving this disclosure. If you cancel coverage, the premium will be prorated and any broker's fee charged for this insurance will be returned to you. D-2-0120 Page 2 of 2 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 ($10D.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706.. INTEREST, AND ATTORNErS FEES. I affirm under r/-,m33jy of perju?y urder Elie Law-F, of California one of the 7011cmmg cleclarativis. (6 1 have and will miaintain a carlificaV-- of corment of self -insure for wmkus' compem—itiorl, by the lkmctar car indlu.strial R-elaforis au provided for ! y Labor Code 3700 for the performance of ff-w- Vocirk set forlh the aircomerit with ". City el El Segundb- 103 OL ft-xil)195-01 e,?l ha-mand wilt by Labor for lhF-perforrnarica of the, work f-x which the agicomerit with the City of El Sequn4io it! Lmecuted- My wui kers' mmp- er=fion insurance carfler and pol,"cy nurnbur arr-- -Car[�Fr I luty Infor-nalionni r Exp,q1t,ort UWA,. G - 13 ? Narric of AqL-rt Jan49 C 12i 7— Phfvir- # — I certify that, in Tic pc-1<mancc ul the wiark F?31 forth sn the 9!9reMi0rit wilh the City of Ei SelXindo, I WHI not empfc,,ry any person in any PrrannjL-, sn, a�� to bocome sxjhjecl to the worker-s' oorr�perisation liaws of I California, nrld agree tha,, if I should become subject to the %vorkois' compenzation provisions od LJbcr Crxle 3700 1' mutt immodieftly comply with rl ipuu prqvisionF, or the ap-e-eme.m will uu bma,io.,jlly IDGrrzu sigrwAvro of Applicacat DAiiFv - K111m Print Nanic Agreemertt for-