PROOF OF INSURANCE (2024) CLOSED
CERTIFICATE OF INSURANCE ENDORSEMENT
SPECIAL EVENT LIABILITY GROUP INSURANCE TRUST, A RISK PURCHASING GROUP
Certificate #31270
FACILITY OWNER - Additional Insured: (if multiple, continued
PRODUCER:CA License #0757776
on next page)
HUB International Insurance Services Inc.
P.O. Box 4047
City of El Segundo, 350 Main Street, El Segundo CA 90245
Concord, CA 94524-4047
specialevent@hubinternational.com
PH: 925 609 6500 FX: 925 609 6550
EVENT HOLDER - Named Insured: (if multiple, continued on
EVENT INFORMATION
next page)
Anna Giannotis TYPE OF EVENT:Instructor
10795 Woodbine Street #1151/11/23 - 1/10/24
EVENT DATE(S):
Los Angeles, CA 90034
300 E. Pine Avenue, El Segundo, CA 90245
EVENT LOCATION(S):
This is to certify that the policies of insurance listed below have been issued to the insured named above for the event date(s) indicated above. 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.
INSURER A: COLONY INSURANCE COMPANY
Type of InsurancePolicy NumberPolicy Limits
INSR LTREffectiveExpiration
Each Occurrence
$1,000,000
General Aggregate
$2,000,000
Personal & Advertising Injury
$1,000,000
Products/Completed Operations
$2,000,000
Aggregate
Commercial
103 GL 00211111/1/2023
A1/1/2024
Damage to Premises Rented to You
General Liability
$1,000,000
Medical Payments
$5,000
Liquor Liability Each Occurrence
(Aggregate included in General
n/a
Liability Aggregate)
COVERAGE TERMS:
Occurrence Form (CG 0001)
The coverage afforded by this insurance is primary and non-contributing with any
Host Liquor Liability Included.
insurance held by the “Additional Insured” as Named Insured, when the “Additional
Insured” is shown on this Certificate of Insurance Endorsement as “Additional Insured”
Full Liquor Liability Included when a
or WHEN REQUIRED BY WRITTEN CONTRACT.
separate premium has been charged.
COVERAGE EXCLUSIONS: (REFER TO POLICY FOR COMPLETE LISTING OF EXCLUSIONS)
-- Communicable Diseases
Specific Events are excluded from coverage. Please see second page for list of excluded events.
-- Sexual Abuse & Molestation
On behalf of the Risk Purchasing Group and each Member, the Trustee has declined coverage for the Terrorism Risk
-- Terrorism
Insurance Act (TRIA).
~ Additional Insureds, next page ~
Second Page of CertificateCertificate #
31270
OTHER ADDITIONAL INSUREDS:
1
2
3
4
5
6
7
8
9
10
11
12
13
CANCELLATION: Should the above described policy(s) be canceled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the insured event
holder and additional insureds listed.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED:
1/11/2023
Third Page of CertificateCertificate #
31270
SPECIFIC EVENT EXCLUSIONS
The following types of events are specifically excluded and no coverage for them exists on the policies listed on the front
page of this Certificate of Insurance:
Aircraft / Aviation
All Terrain Boarding
Ballooning / Balloon Rides
Base Jumping
Bouldering Events
Boxing, Wrestling
Bungee Jumping
Carnival Rides
Circuses
Concerts with single performances exceeding 6 hours of performance time
Contact Karate / Martial Arts
Contact Sports
Diving
Football (except passing camps with no contact drills)
Hang Gliding
Hockey
Jousting
Kayaking, Rafting or Canoeing in greater than Class 3 rapids
Lacrosse / Rugby
Mechanical Amusement Rides or Services and Gyroscope Rides
Motorized Sporting Equipment
Mosh Pits
Mountain Biking
Power Boat Racing
Professional Sporting Activity; Games, Races, Contests of a professional nature
Pyrotechnics / Explosives
Rap or Heavy Metal Concerts
Raves
Rock Climbing, Climbing Wall
Rodeo / Roping Events (includes practice)
Scuba Diving
Tractor / Truck Pulls
Zip Line / Zip Lining
POLICY #103 GL 0021111
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IF CAREFULLY.
SEPARATION OF INSUREDS - INSURED MEMBERS
AND REPORTING ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
A.
SECTIONI-COVERAGES,COVERAGEABODILYINJURYANDPROPERTYDAMAGELIABILITY,2.
Exclusions,and COVERAGEBPERSONALANDADVERTISINGINJURYLIABILITY,2.Exclusions ofthe
COMMERCIALGENERALLIABILITYCOVERAGEFORM,and SECTIONI-LIQUORLIABILITY
COVERAGE, 2. Exclusions of the LIQUOR LIABILITY COVERAGE FORM are amended and the following added:
This insurance does not apply to:
Unreported Events
“Bodilyinjury”,“propertydamage”,“personalandadvertisinginjury”or“injury”arisingoutofany“InsuredMember(s)”
thatyouhavenotreportedinthePolicyholder’sBordereaux,subjectto SECTIONIVCOMMERCIALGENERAL
LIABILITY CONDITIONS, Reporting Provisions added in item E. below.
However,thisprovisiondoesnotapplyintheeventofanunintentionalerrororomissioninnotreportingan“Insured
Member”inthePolicyholder’sBordereauxifsuch“InsuredMember”receivedaCertificateofInsuranceandpaidthe
premiumpriortothe“bodilyinjury”,“propertydamage”or“personalandadvertisinginjury’or“injury”thatresultedina
claim or “suit”.
B. SECTIONIl-WHOISANINSURED,1.a.ofthe COMMERCIALGENERALLIABIUTY and LIQUOR
LIABILITY COVERAGE FORMS, is deleted and replaced with the following:
a. Anindividual,youandyourspouseareanamedinsured,butonlywithrespecttoyourconductasan“Insured
Member” named on the Certificate of Insurance referenced in item C. below.
C.
SECTIONII-WHOISANINSURED ofthe COMMERCIALGENERALLIABILITY and LIQUORLIABILITY
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. SECTIONIV-COMMERCIALGENERALLIABILITY and LIQUORLIABILITYCONDITIONS,7.Separation
Of lnsureds 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
T1523-0111Page 1 of 3
b. separately to each “Insured Member” against whom claim is made or “suit’ is brought.
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.
SECTIONIV-COMMERCIALGENERALLIABILITYCONDITIONS and SECTIONIV-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 Policyholders
Bordereaux, you must include a copy of the Certificate of Insurance issued evidencing the
“Insured Members” 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”.
T1523-0111Page 2 of 3
F. SECTIONIV-COMMERCIALGENERALLIABILITY and SECTIONIV-LIQUORLIABILITY
CONDITIONS, 5. Premium Audit, are deleted and replaced with the following:
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.
T1523-0111Page 3 of 3