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PROOF OF INSURANCE (2023 - 2023) CLOSEDDATE (MM/DDNYYY) w CERTIFICATE OF LIABILITY INSURANCE 9/20/2022 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: Catherine Plaia NONE x Western C Nc ) FA 19900 Beach Ih3lvdInstarance Services ADDRESS: C t 1714,53 1�ri�r.6 ®f00 _p...... ...._............. ce coin ...................................... ............ ................... ............................................................................ ......................... .................. ......... Suite F I INSURER(S) AFFORDING COVERAGE NAIC # ..... ........................................................... ...................................... _..._......................................................................... ..................................................................... Huntington Beach CA 92648 INSURER A: PHILADELPHIA IND INS CO 18058 .... ....� . ......... INSURED ... ... '..INSURER B :: Jaguar Tcnnis Academy, LLC INSURER c _ ... 401 Sheldon St INSURER D : ... ...................................................................................................................................................................................................................................................................... INSURER E : F1 Segundo CA 90245-4013 INSURER F : CnVFRAr_FR CERTIFICATE NI IMRFR• RFVIRInN NIIMRFR• 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 CONTRACTOR 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, ALIUL 'R TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS JCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ W CLAIMS-MADE191 OCCUR PREMISES,•(•Ea occurrence) $ GEN'L AGGREGATE LIMIT APPLIES PER: ❑T ❑ POLICY J�E.JECC1', LOC ''...... OTHER: AUTOMOBILE LIABILITY ANY AUTO ..OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY R AUTOS ONLY UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE RETENTION $ EMPLOYERS' LIABILITY Y / N PROPRIETOR/PARTNER/EXECUTIVE CER/MEMBER EXCLUDED? N / A datory in NH) ,descnbe under vRIPTION OF OPERATIONS below (Any one per son) S MED EXP �......................._ ....... 09/11/2022 09/11/2023 PERSONAL BADVINJURY n GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG •••• S $ $ ....... ......... ........i*J1J9P� 311+TSLE T.1T AI H .... (Ea acvdrv)a) $ BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE S (Pr r auzatleriQ S EACH OCCURRENCE'S AGGREGATE $ $ E L EACH ACCIDENT S E,L. DISEASE - EA EMPLOYEE $ E I DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. Certificate holder is recognized as an additional insured in regard to the General Liability policy per the PI-AS-010 endorsement. The City of EI Segundo, its officers, officials, employees agents and volunteers ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �l'�4A'LwP P�-t.0•� © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD "xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Kocxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Koaxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 3XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx=xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx o xXaxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx �xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx �xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx CALIFORNIA INSURANCE VEHICLE IDENTIFICATION CARD CALIFORNIA INSURANCE VEHICLE IDENTIFICATION CARD i POLICY NUMBER POLICY NUMBER 32400050 - 32400050 3 ] i 'tamed Sergiu Boerca Named Sergiu Boerica nsured Insured 11111INlIMMI III, 4ddress 906 E Imperial Ave UNIT 1 Address 908E Imperial Ave UNIT 1 El Segundo CA 90245-2519 El Segundo CA 90245-2519 =ROM Sep 24, 2022 TO Mar 24, 2023 FROM Sep 24, 2022 TO Mar 24, 2023 YEAR MAKE VEHICLE ID NUMBER YEAR MAKE VEHICLE ID NUMBER 2011 Mazda ' 2011 Mazda :OVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS 3RESCRIBED BY LAW PRESCRIBED BY LAW SEE IMPORTANT NOTICE ON REVERSE SIDE NAIC NUMBER: 10683 SEE IMPORTANT NOTICE ON REVERSE SIDE NAIC NUMBER: 10683 i ---------------- -- - CALIFORNIA INSURANCE VEHICLE IDENTIFICATION CARDIDII$s =ffi��CALIFORNIA INSURANCE VEHICLE IDENTIFICATION CARDaa�� _ E i POLICY NUMBER POLICY NUMBER 32400050 jjnUmfice 32400050 %arced Sergiu Soerica Named Sergiu Boerica nsured = Insured 4ddress 906 E Imperial Ave UNIT 1 Address 906 E Imperial Ave UNIT 1 El Segundo CA 90245-2519 El Segundo CA 90245-2519 =ROM Sep 24, 2022 TO Mar 24, 2023 FROM Sep 24, 2022 TO Mar 24. 2023 YEAR' _.- — — - — - -k VEHICLE ID N- UMBER YEAR � VEHICLE IO NUMISER—' 2002 Ford 2002 Ford __ ... :OVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS ;COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS 2RESCRIBED BY LAW PRESCRIBED BY LAW a SEE IMPORTANT NOTICE ON REVERSE SIDE NAIC NUMBER: 10683 SEE IMPORTANT NOTICE ON REVERSE SIDE NAIC NUMBER: 10683 i i i 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: L_) 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 # LX_) 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 I must immediately cornply with those provisions or the agreement will automatically become void. Signature of Applicant Date Agreement for: Dated: Reviewed by: