PROOF OF INSURANCE (2023) CLOSEDK&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne, IN 46804
Phone 1-877-648-6404
Fax 1-260-459-5502
tI * www"A flaill!
Claims 1-800-237-2917
Are you an insurance agent or yes
broker?
Named insured (as it should Natalie Strong
appear on the policy):
Doing business as (DBA):
Contact first name: Natale
Contact last name: Strong
Mailing address:
City: ElSegundo State: California
Phone: IMF Fax:
E-mail:
Website:
This is a renewal of coverage
I do NOT wish to receive a
commission
Agency name:
Agency mailing address:
C ity:
Agent/contact first name:
Agent/contact last name:
Agency phone:
Agent/contact e-mail:
A
Zip: 90245
Cell:
Merriwether & Williams Insurance Services
44 Montgomery St, Ste 940
San Francisco State: California Zip: 94104
Janet
Ramirez
213-258-3096 Agency 213-258-3099
fax:
"',ramiirez imwis.com
Selected operation(s):
Coverage effective date(s):
In which state is the insured located?
Where is the insured's primary location or facility?
Type of organization:
Are you seeking coverage for all members/participants of your club?
Are you responsible for the ownership, operation or maintenance of a facility?
Do you host, sponsor or organize any activities or events that are open to the
public?
Do your club activities involve any of the following?
Art
09/17/2022 to
09/17/2023
California
California
Individual
club/group
Yes
No
No
No
Acrobatic or circus performing programs; Addiction support groups; Boy scouts or girl scouts;
Boys or girls clubs; Country clubs; Dating clubs, programs or organizations; Day care or adult
before and/or after school care operations, latch key programs, babysitting or childcare clubs or
programs; Faith based/religious studies; Fitness clubs; Fraternities or sororities; Groups under
the direction of a professional counselor or therapist; Historical battle re-enactment groups;
Instruction in first aid, CPR, or life-saving/life guarding; Nutritional and weight loss programs;
Political activist and/or governmental groups; Programs dedicated to discipline, rehabilitation or
behavior modification; Programs or activities involving animals; Programs or activities that
involve weapons or firearms; School accredited classes or programs; Senior centers; Sports
teams, leagues or associations or sporting events/activities; Vehicle owner clubs; Veterans or
military organizations (eg: American Legion, Elks, Moose, Knights of Columbus);
Wine/beer/alcohol clubs
Each Occurrence:
$ 1,000,000
General Aggregate (other than Products -completed Operations):
$ 5,000,000
Products -completed Operations Aggregate:
$ 1,000,000
Personal and Advertising Injury:
$ 1,000,000
Damage to Premises Rented to You:
$ 1,000,000
Medical Expense (other than participants):
$ 5,000
Hired Auto and Employers' Nonownership Liability (not provided while
$ 1,000,000
in Hawaii):
Professional Liability:
$ 1,000,000
Bodily Injury to Participants:
$ 1,000,000
Medical Payments for Participants (excess) - $100 per claim deductible
$ 25,000
applies:
Provide the number of participants for each activity:
Art 25
Commercial General Liability Premium:
$ 00.00
Abuse, Molestation, Harassment or Sexual Conduct Defense Cost
Reimbursement
Do you want to add this coverage to the quote? No, Thank you
Notable Exclusions:
Abuse, molestation, harassmentor sexual- conduct (unless optional liability coverage is purchased);
Activities or events hosted, sponsored or organized' by the insured that are open to the public;"'
Aircraft/hot air balloon; Airport; Amusement devices (The ownership, operation, maintenance or use of:
any mechanical or non -mechanical ride, slide, or water slide, any inflatable recreational device, any
bungee operation or equipment, any vertical device or equipment used for climbing -either permanently
affixed or temporarily erected, or dunk tank. Amusement device does not include any video arcade or
computer games or structures that are not designed to bounce on, slide on, ride on, or tunnel through); >
Animals (injury or death to, or injury, death or property damage caused by any animal owned, rented or
hired by you); Any events or activities involving or _promoting tobacco or cannabis; Asbestos; Cap on
losses from certified acts of 'terrorism; Commercial general liability standard exclusions (CG0001 04/13
edition); Communicable Disease; Cyber incident, data compromise and violation of statutes related to
personal data; Employment -related practices;, Events where'the insuredisrequired to hold a liquor
license or permit; Fireworks; Fungi or bacteria; Gambling activities or events; Haunted attractions; Hiking
on ungroomed trails or orienteering; ,In or on water activities; Lead; Nuclear energy liability; Operation,
ownership or management of any facility or premises,: other than while being used for covered activities;
Outside concessionaires and vendors in conjunction with your organization; Sexually transmitted
diseases; Silica or silica -related dust; The use of power tools, unmanned aircrafts and combustion; Total
pollution with a building heating, cooling,& dehumidifying equipment exception and hostile fire exception;
Transportation of members or participants;Those operations' listed as ineligible: Acrobatic or circus
performing programs, Addiction support groups, Boys and girls clubs, Boy or Girl Scouts, Country clubs,
Dating clubs, programs or organizations, Day care and/or adult before or after school care operations,
latch key programs, babysitting or childcare clubs or programs, Faith -based or religious studies, Fitness
clubs, Fraternities' or sororities,_ Groups under the direction of a professional counselor or therapist,
Historical battle re' -enactment groups, Instruction in first aid, CPR, or life saving/life guarding techniques,
Nutritional and weight loss programs, Political, activist and/or governmental groups, Programs dedicated
to discipline, rehabilitation or behavioral modification, Programs or activities involving animals, Programs
or activities that involve weapons or firearms, School accredited classes, programs or clubs, senior
centers, Sports teams, leagues or associations or sporting events/activities, Vehicle owner clubs,
Veterans or military organizations, Wine/beer/alcohol clubs.
Terms & Conditions:
1. Premiums are 100 % fully earned when coverage begins and non-refundable. Premium for Sexual
Abuse/Sexual Molestation coverage, if purchased, is 100% earned.
2. Any exposure changes that deviate from the original enrollment form must be reported in writing.
3. Acceptance of this quote confirms your desire to obtain liability insurance through the Sports,
Leisure and Entertainment Risk Purchasing Group. K&K reserves the right to decline any request
for coverage.
4. Coverage is contingent upon receipt of premium payment. No coverage will be deemed in effect
until premium is received by the company or their representative.
5. Commercial General Liability Broadening Endorsement:
• Expected or intended bodily injury or property damage resulting from the use of
reasonable force to protect persons or property.
• Non -owned Watercraft - extended to 58 feet.
• Supplementary Payments - $2,500 bail bonds, $500 a day loss of earnings.
• Waiver of Right of Recovery.
• Bodily Injury definition expanded to include mental anguish, mental injury, shock, fright,
humiliation, emotional distress or death resulting from bodily injury, sickness or disease.
• Damage to Premises Rented to You - the term fire is replaced with fire, lightning,
explosion, smoke and leaks from sprinklers.
• Additional Coverage:
• Emergency Real Estate Consultant Fee - $25,000
• Identity Theft Exposure - $25,000
• Key Individual Replacement Cost - $50,000
• Lease Cancellation Moving Expense - $2,500
• Temporary Meeting Space - $25,000
o Terrorism Travel Reimbursement - $25,000
• Workplace Violence Counseling - $25,000
Do you need to request any additional Certificate(s) of Insurance to present to a third Yes
party?
Entity name: City of El Segundo
Mailing address: 350 Main St.
City: ElSegundo State: California Zip: 90245
Relationship: Owner, manager or lessor of premises
I understand that the insurance company, in determining whether to provide insurance coverage, will
rely on the information contained in this form and all other information being submitted. I hereby
warrant, represent and confirm that, to the best of my knowledge, all information provided is
complete, true and correct.
rJ I accept, on behalf of the Insured
I am aware that the insurance company expects accurate reporting for my premium calculation, and
should my figures exceed my estimates during the coverage term I will make arrangements to pay
the additional premium. I understand that my book and records may be examined or audited by the
insurance company at any time during the coverage period and up to three years thereafter.
Intentional misrepresentation or misreporting may jeopardize coverage. K&K reserves the right to
decline/void any ineligible coverage.
V I accept, on behalf of the Insured
I further acknowledge that, I have reviewed all information provided with this enrollment form and
understand the exclusions which apply, as well as the activities and operations for which coverage is
not provided. The information I provided on this enrollment form becomes a part of the insurance
contract.
W I accept, on behalf of the Insured
I represent and warrant as an insurance producer that I currently maintain, and will maintain, all
individual, corporate or agency licenses or permits required in order to conduct insurance business in
the state coverage for this insured is being written. I further represent and warrant that I currently
maintain, and will maintain, errors and omissions insurance with a minimum limit of $1,000,000 for
myself, my officers, and employees. If requested by K&K, I will provide K&K with reasonably
satisfactory evidence of all of the above mentioned items.
RPG Administration Fee $15.00
* Premium subject to change if not completing purchase same day as quoting *
This summary is not a contract of insurance. You must refer to the actual policy for complete information
regarding coverage terms, conditions and exclusions, as they may change from one coverage period to
the next. Please remember that you will receive evidence of coverage immediately if purchased online.
You may request copy of the full policy by submitting a written request.
Acceptance of this quote confirms your desire to obtain liability insurancethrough the Sports, Leisure
and Entertainment Risk Purchasing Group (where applicable). An RPG provides group purchasingpower
for similar risks resulting in potential advantageous coverage terms, competitive rates, risk management
bulletins, and rewards for favorable group loss experience.
_ An RPG administration fee may be charged.
Fair Credit Report Act Notice
Personal information about you, including information from a credit or other investigative report, may
be collected from persons other than you in connection with this application for insurance and
subsequent amendments and renewals. Such information as well as other personal and privileged
information collected by us or our agents may in, certain circumstances be disclosed to third parties
without your authorization. Credit scoring information may be used to help determine either your
eligibility for insurance or the premium you will be charged. We may use a third party in connection
with the development of your score. You have the right to review your personal information in our files
and can request correction of any inaccuracies. A more detailed description of your rights and our
practices regarding such information is available upon request. Contact your agent or broker for
instructions on how to submit a request to us.
Fraud Warning
Applicable in AL, AR, DC, LA, MD, NM, RI and; WV: Any person who knowingly (or willfully)*
presents a false or fraudulent claim' for payment of a loss or benefit or knowingly (or willfully)*
presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison. *Applies in MD only.
Applicable in CO: It is unlawful to knowingly ,provide 'false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the
company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly_ provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with 'intent to injure, defraud, or deceive
any insurer files a statement of claim or an application containing any false, incomplete, or misleading
information is guilty of a felony (of the third degree)*. *Applies in FL only.
Applicable in KS: Any person who, knowingly and with 'intent to defraud, presents, causes to be
presented or prepares with knowledge or belief that it will be presented to or by an insurer,' purported'
insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile,' magnetic,
oral, or telephonic communication or statement as part of, or in support ;of, an application for the
issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for
payment or other benefit pursuant to an insurance policy for commercial or personal insurance which
such person knows to contain materially false information concerning any fact material thereto; or
conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act.
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for
each such violation)*. *Applies in NY only.
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties
(may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME only.
Applicable in MN: A person who files a claim with intent to defraud or helps commit a fraud against
an insurer is guilty of a crime.
Applicable in NJ: Any person who includes any false or misleading information on an application for
an insurance policy is subject to criminal and civil penalties.
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud
the insurer by, submitting an application containing a false statement as to any material fact may be
violating state law.
Applicable in VT: Any person who knowingly presents a false statement in an application for
insurance may be guilty of a criminal offense and subject to penalties under state law.
Applicable in all other states: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent' insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Copyright 2009 K&K Insurance Group Inc.,
K&K Insurance Group, Inc. is a licensed insurance producer in all states (FL license ,';LJ07299, TX license
�13924);
-)perat;ng in CA, NY and MI as K&K Insurance Agency (CA License 0334819)
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 #
yl certify that, in the performance of the work set forth in the agreement with the City of El Segundo, i will not
ggrKee
oy any person in any manner so become subject to the workers' compensation laws of California, and
that, wf I shout co su to lie workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with th tie agreement will automatically become void.
Signature of Appl c 2a t
Date
I Print Name
i
Agreement ent for: el A tli-5 `4 C 191 ~
Dated; 11/12/21
Reviewed by:
Hank Lu, Risk Manager