PROOF OF INSURANCE (2023 - 2024) CLOSEDMARKEL INSURANCE COMPANY
III
RELY.
MEMBER CERTIFICATE
CERTIFICATE NUMBER: 2002596381 11/17/2022 DATE: November 17, 2022
THIS CERTIFICATE REPRESENTS INSURANCE PROVIDED IN ACCORDANCE WITH THE FOLLOWING:.
MASTER POLICY NUMBER: M1 RPG000000O030800
FIRST NAMED INSURED (MASTER POLICY HOLDER): Sports, Leisure and Entertainment Risk Purchasing Group
IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THE MASTER
POLICY, WE AGREE TO PROVIDE THE INSURANCE AS STATED IN THIS CERTIFICATE.
NAMED INSURED (CERTIFICATE HOLDER)
Name and Mailing Address (No., Street, Town or City, State, Zip Code):.
Wanda Borgerding
DBA: Musical Fun For Tots
Effective Date: 01A 0/23 at 12:01 a.m. Standard Time at the address shown above.
Expiration Date: 01/10/24
This replaces prior Certificate Number:
Plan Administered By
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne, IN 46804
Contact Information
Name: MM - Independent Instructor of Arts/Sciences
Phone: 1-800-506-4856
Fax: 1-260-459-5502
Email: info@fitnessinsurance-kk.com
To Report A Claim
By Phone: 1-800-237-2917
By Fax: 1-312-381-9077
By E-mail: KK.Claims@kandkinsurance.com
K&K Insurance Group, Inc.
By Mail: 1712 Magnavox Way P.O. Box 2338
Fort Wayne, Indiana 46801
Online: www.kandkinsurance.com
Insurer
Markel Insurance Company
10275 West Higgins Road, Suite 750
Rosemont, IL 60018
Producer Name And Mailing Address
K&K Insurance Group, Inc
1712 Magnavox Way
Fort Wayne, IN 46804
MCGL 1002 07 21 Page 1 of 2
Description Of Operations, Premises, And Operations
Description Of Operations: Instructor of: Instructor music, Vocals
Premises And Operations
Location No. Address Operations
Refer to MGL 1576
Limits Of Insurance
Commercial General Liability
General Aggregate: $5,000,000
Products/Completed Operations Aggregate: $1,000,000
Personal And Advertising Injury: $1,000,000 Any One Person Or Organization
Each Occurrence: $1,000,000
Damage To Premises Rented To You: $1,000,000 Any One Premises
Medical Expense: $5,000 Any One Person
Additional Coverages
In addition to the Commercial General Liability coverages shown above, the following additional coverages are provided.
If a coverage is not listed below, such coverage, including its corresponding endorsement, does not apply to this Member
Certificate.
Limit Of Insurance
Bodily Injury to Participants $1,000,000 Each Occurrence
Professional Liability $1,000,000 Each Wrongful Act Limit
Endorsements
Forms and endorsements applying to this Member Certificate and made part of this policy at time of issue:
Refer to master policy including all state amendatory endorsements applicable to the state of this Member Certificate,
This Member Certificate, together with the Coverage Form and any Endorsement(s) attached
to the Master Policy, complete the above numbered certificate. Coverage is subject to all
terms, conditions, limitations, exclusions, and other provisions contained therein.
Member Certificate Premium
Commercial General Liability Premium: $140.00
To review the Master Policy: Please send a written request to the Plan Administrator shown above.
Countersigned: November 17, 2022
Date
By. -X—�
AUTHORIZED REPRESENTATIVE
MCGL 1002 07 21 Page 2 of 2
PRODUCER —
BICHLMEIER INS SVCS INC 042789 07
730 S PACIFIC COAST HWY //201 INSURANCE COhfPAY
DONDO BEACH, CA 90277 AUTOMOBILE POLICY DECLARATIONS
APIIIAI(I GG° IMPORTANT COVERAGE EXCLUSION
TELEPHONE (310) 376 8852
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0401 07 150084433 F-08/26/2022u,omm 1002/26/20231xDiAII "I(UII S, Re I I1 T(ij1(S( 1 Ylbtdl MDW1! I1 �. ER
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WANDA B BORGERDING
DRIVERS „ 4�atiiiltllldd far°A1511T@1zr.Ngi. errorlil.Ilidagfilu ¢lclde . r:
WANDA� BORGMMI�ING .
MAILING 531 AVENUE A APT D ®®®
ADDRESS REDONDO BEACH, CA 90277-4859
1C NEAR11 t1 t 'M liiluC , , ; ERIa fi0MdC tl E'°`. NEtiiddlJ�
1 2014 KIA SORENTO SX/SX LI UTL 4X2 4D ' f1 �d�lGiD
2 2016 LEXUS ES 350 SED 4DR U 11 /2014
U 01/2019
FCgpq tG�Ftttllpp'10.ta�SdYk[IRYhkiitbdF9Yi{dSlClkMlhkNIxaBIXlkdpSlMYEaI4i5 IYdR411UiZTIWr&iSA6a�dGCpIpC4tER&dtNpr6d$dduCY"t}fpgi}irbYNkAdl3ilsYibYk ww..,
.. W ._......... .... .....
Coverage applies only if premium charge is listed below. Coverage/Limits are subject to all policy terms.
.,11yi11I$"FiAIIl1Y..,., :, .,. PR -I :#VICP.ICiLDFRt21,llutiD
BODILY INJURY LIABILITY $100,000 EACHPERSON $ 300,000 EncHAcGDENr CAR CAR2 CAR ITEMS INSURED AND AMOUNTS OF '
176 103 INSURANCE FOR EACH ITEM ARE STATED
PROPERTY DAMAGE LIABILITY $100,000 EACH ACCIDENT 250 130 HEREIN, ITEMS INSURED ARE SUBJECT TO
THE DEDUCTIBLE.
BODILY INJURY LIABILITY $ 100,000 EACH PERSON $ 300,000 EACHACCIDENT 64 47
UNINSURED MOTORISTS
PROPERTY DAMAGE LIABILITY
$ MAXIMUM
COLLISION DEDUCTIBLE W19AIV
MEDICAL EXPENSE $
.........
LEASEILOAN GAP COVERAGE CAR CAR CAR
REPAIR
R REPLACEMENT CAR CAR CAR
TCOV
ERAGE
COMPREHENSIVE DEDUCTIBLECAR1 $500 CAR2 $500 CAR $ 15 20 " 'RIJUkASS . ME'NTS
COLLISION DEDUCTIBLE CAR1 $ 500 CAR2 $500 CAR $ 205 229 CA FRAUD FEE ) .76
ROADSIDE ASSISTANCE EACH -.....—
(FOR TOWING SERVICES)' OCCURRENCECARI $75 CAR2 $75 CAR 4 4 CIGA FEE
RENTAL CAR BENEFIT $40 PER DAY 30 DAYS 29 29 WTERVENOR FEE
U-10 12/2021 746 � 565
TOTAL PREMIUM 1,312.76
IMPORTANT INFORMATION
*For Non -Towing Services, Limit of Liability is $75 per Occurrence. Maximum 5 Occurrences in total for
"Towing and Non -Towing services per policy period,
EFFECTIVE 08/26/2022
The enclosed Auto Insurance Renewal Bill and the U251 IMPORTANT NOTICE are part of this policy. These
specify the amount of your premium, your payment options„ any applicable fees, and the due date.
Your automobile insurance expires and coverage ceases at 12:01AM on 08/26/2022. Coverage under
this policy will become effective provided you pay the premium and any applicable, fees as indicated
on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent or broker at
the phone number provided above.
MAILED TO:
WANDA B BORGERDING
AVENUE A APT D
RE '?L( Nit°IV9sER, 0401 07 150084433
REAVENUE
BEACH, CA 90277-4859
!l1LIIVG?fiTE`; 07/27/2022
U-17B
INSURED COPY
�11 UN-4
This policy is continuous until cancelled or nonrenewed with respect to the interest of the Loss Payeels) or Additional
Interest(s) named on the reverse side hereof.
LOSS PAYABLE ENDORSEMENT
a�
With respect to the interest of the loss payee named on the reverse side hereof, its successors and assigns, (hereinafter called the
Lien -Holder) in its capacity as conditional Vendor or Mortgagee or otherwise, in the property insured under this policy, this Company hereby
® agrees as follows:
i® 1. Loss or damage, if any, to the property described in this policy shall be payable firstly to the Lien -Holder and secondly to the insured, as
their interests may appear, provided nevertheless that upon demand by the Lien -Holder upon the Company for separate settlement the
amount of said loss shall be paid directly to the Lien -Holder to the extent of its interest and the balance, if any, shall be payable to the
insured.
2. The insurance under this policy as to the interest only of the Lien -Holder shall not be impaired in any way by any change in the title or
ownership of the property or by any breach of warranty or condition of the policy, or by any omission or neglect, or by the performance
of any act in violation of any terms or conditions of the policy or because of the failure to perform any act required by the terms or
o conditions of the policy or because of the subjection of the property to any conditions, use or operation not permitted by the policy or
because of any false statement concerning this policy or the subject thereof, by the insured or the insured's employees, agents or
representatives; whether occuring before or after the attachment of this agreement, or whether before or after the loss;
PROVIDED, however, that the wrongful conversion, embezzlement or secretion by the Purchaser, Mortgagor, or Lessee in possession of
a the insured property under mortgage, conditional sale contract, lease agreement, or other contract is not covered under this policy,
r
unless specifically insured against and premium paid therefor.
3. In the event of failure of the insured to pay any premium or additional premium which shall be or become due under the terms of this
policy, this Company agrees to give written notice to the Lien -Holder of such nonpayment of premium. The rights of the Lien -Holder
under this Automobile Loss Payable Endorsement shall not be terminated before ten (10) days after the mailing of such notice.
4. If the Company elects to cancel this policy in whole or in part for nonpayment of premium, or for any other reason, the Company will
forward a copy of the cancellation notice to the Lien -Holder at its office specified hereinafter concurrently with the sending of notice to
the insured but in such case this policy shall continue in force for the benefit of the Lien -Holder only for ten 110) days after written
notice of such cancellation. In no event, as to the interest only of the Lien -Holder, shall cancellation of any insurance under this policy
covering the property described in the policy be effected at the request of the insured before ten (10) days after written notice of
cancellation shall have been given to the Lien -Holder by the Company. In the event of cancellation of this policy the unearned premium
shall be paid to the Lien -Holder, provided the said Lien -Holder has advanced the premium.
5. If there be any other insuranco upon the within -described property, this Company shall be liable under this policy as to the Lien -Holder
only for the proportion of such loss or damage that the sum hereby insured bears to the whole amount of valid and collectible insurance
of similar character on said property under policies held by, payable to and expressly consented to by the Lien -Holder, and to the extent
of payment so made this Company shall be subrogated (pro rata with all other insurers contributing to said payment) to all of the
Lien -Holder's rights of contribution under said other insurance.
6. Whenever this Company shall pay to the Lien -Holder any sum for loss or damage under this policy and shall claim that as to the insured
no liability therefor exists, this Company at its option, may pay to the Lien -Holder the whole principal sum and interest due or to
become due from the insured on the obligation secured by the property insured under this policy, (with refund of all interest not
accrued), and this Company shall thereupon receive a full assignment and transfer, without recourse, of said obligation and the security
held as collateral thereto; but no subrogation shall impair the right of the Lien -Holder to recover the full amount of its claim.
7„. The coverage granted under this policy shall continue in full force and effect as to the interest of the Lien -holder only, for a period of
ten (10) days after expiration of said policy unless an acceptable policy in renewal thereof with loss thereunder payable to the
Lien -Holder in accordance with the terms of this Automobile Loss Payable Endorsement shall have been issued by some insurance
company and accepted by the Lien -Holder. In the event of a loss not otherwise covered during the extended ten (10) day period herein
referred to, an annual policy covering the same hazards to the property insured under the original policy shall be issued and accepted by
the Lien -Holder and Mortgagor.
. Should the ownership and right of possession of any of the property covered under this policy become vested in the Lien -Holder or its
agent, this policy shall continue for the term thereof for the benefit of the Lien -Holder (with all incidents of ownership or the policy) but,
in such event, Paragraphs two 121, five (5), and six (6) of this Automobile Loss Payable Endorsement shall no longer apply; provided,
nevertheless, all privileges and endorsements which, by reason of the printed conditions of this policy, are or may be necessary to
maintain the validity of the contract, and hereby granted for a period of thirty (30) days and all notices likewise required to be given to
the Company by the insured are hereby waived for a period of thirty (30) days with the exception of requirements applying at the time
of or subsequent to a loss.
9. All notices herein provided to be given by the Company to the Lien -Haider in connection with this policy and this Automobile Loss
Payable Endorsement shall be mailed to or delivered to the Lien -Holder at its office or branch as set forth on the reverse side hereof.
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, agreements or limitations of the above
mentioned policy, other than as above stated.
U-49A (Revised)
ADDITIONAL INTEREST ENDORSEMENT
If this policy is cancelled, prior to its expiration date, ten (10) days advance notice of such cancellation will be given to the additional interest
named on the reverse side. Only the bodily injury and property damage liability insurance provided by the policy, to "any other person or
organization" extends to the additional interest. This does not affect the coverage provided by the policy, to any other insured.
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: