PROOF OF INSURANCE (2022 - 2023) CLOSEDL CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
10/25/2022
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 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: _ ______
Next First Insurance Agency, Inc. PHONE FAX
(855) 222-5919 A3C Ne
P0Box 60787 ------ ......... (-.....1 .,.,.._
Palo Alto, CA 94306 ;'nnRr- q. support@nextinsurance.com
INSURED
Novo Gym Repair Inc
1875 W Redondo Beach Blvd Ste 200
Gardena, CA 90247
INSURER B :
INSURER C :
INSURER E :
StatelNationalsInsurance Company�nc. ]1283NAIC#
COVERAGES CERTIFICATE NUMBER:307180422 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.
.......................... ... _ .... ........ .
.E ..............................- ......... ............ ........ . ....
INSR pDD� SM11BR� �
TYPE OF INSURANCE POLICY NUMBER..."".. MMMDIY'YYY mmioDCYYYY....
LTR LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $1,000,000.00
...........
��
i57�IG971(� rC F! Y FtS ._-_ .__. _..
CLAIMS -MADE OCCUR
PREMISES Ee,accurrence IT $100,000.00
... _....._
MED EXP. . ,.... erson) $10,000.0
(Any one 0
A
X
NXT7YT7DL3-00-GL
09/30/2022
09/30/2023
PERSONAL $1,000,000.00
... - ...... .... .. ....
GEN'LAGGREGATELIMITAPPLIESPER:
GENERALAGGREGATE $1,000,00000
X
C El
POLICY JPF LOG
PRODUCTS - COMP/OP AGG $1,000,000.00
.............a._._._._._....._._....,-................__.. ...
OTHER:
$
AUTOMOBILE
COMBINED SINGLELIMIT
$
ANY AUTO
BODILY INJURY (Per person)
$
OWNED
AUTOS ONLY IAUTOS ULED
DI INJURY a
BODILY N cadent ),
$
HIRED NON -OWNED
d � � GYOANtAAG
_
$
AUTOS ONLY AUTOS ONLY
� s rrt
I.. ...
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
EXCESS LIAB CLAIMS MADE
AGGREGATE
$
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y�
IN
PER OTH
STATUTE ER
$
ANYPROPRIETOR/PARTNER/EXECUTIVE " """
E.L. EACH ACCIDENT
$
OFFICER/MEMBEREXCLUDED?
N / A�
(Mandatory in NH)
E.L DISEASE EA EMPLOYEE
$
If yes, describe under
e
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"" """'""'"'"""" """"�"'
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
Each Occurrence: $10,000.00
A
Contractors Errors and Omissions
X
NXT7YT7DL3-00-GL
09/30/2022
09/30/2023
,Aggregate: $20,000.00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
The Certificate Holder is El Segundo Police Department. This Certificate Holder is an Additional Insured on the General Liability polic pper the Additional Insured Automatic
Status (Endorsement. All Certificate Holder privilege; apply only if required by written agreement between the Certificate Holder anNe insured, and are subject to policy
terms and conditions.
CERTIFICATE HOLDER CANCELLATION
El Segundo Police Department LIVE CERTIFICATE
348 Main St rat I7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
El Segundo, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Click or stern to view
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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DECLARATION
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POLICY NUMBER, 504-61016_693 ro0E1
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POLICY
PERIOD12115/021NEW ro., 1211512022
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This policy NS effecfive n earlier
LOS A GE E'S 44' i,41�'.38" �
than the, r�� OI�uO Wne fin
Which th6 O ip icafl0ri I$ rig ted
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PREMIUMS FOR VEHICLES
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07/1 2f 2022 AMEND CIATE',
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INS�1 // / /, , ; r ' I,// l� i, / ! / %// , RSEMENT:
, / /r/�ji/i�ii/ // ii� //l�/� '/�iiii END O
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WARNING; FAILURE°l
IS UNLAWFUL AND SUBJECTS AN EMPLOYERTO 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 #
I 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 provisi f"ts, r` the agreement will automatically become void.
Signature of Applicant �� " " Dates
Agreement for:
Dated: