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PROOF OF INSURANCE (2024 - 2024) CLOSEDAi U
10
CC>R CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
10/2/2023
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,Christine So
Alliant Insurance Services, Inc.
--
PHONE (855) 827-9642 FAX
(NC,NQI: (703) 563 1510
Barry Peters
Eb"AIV —
AaDR Ss, yoga-questioris al1iani.coni
4530 Walney Rd Ste 200
—
Chantilly, VA 20151-2285
_._ .... INSURER(S)AFFORDINGCOVERAGE NAIC#
. ...
INSURER A . Lloyd's of London 1126609
INSURED
Julia Nicole Levee
INSURER B :
----- -
INSURER C :
NSURER D :
El Segundo, CA 90245
JWRERE:
INSURER F
COVERAGES CERTIFICATE NUMBER: 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.
...,., m., ......
......... �DDI'�''GSE.,......,, .--.."POLICXNUMBER.,-."""""" --.MMfD Y".
INRI.. ,TYPE
OF INSURANCE MMF27D.FF
INSD LIMITS
COMMERCIAL GENERALLIABILITY
EACH OCCURRENCE
$ $1 00O 000
X
YOGAI859240 1
10/14/2023
10/14/2024
yrµ ^pup yryvywyvrv��µ�
"PREMMISES
100,0_00
mX
CLAIMS -MADE _a OCCUR
Eaoccurrenszt
$
MED EXP (Any one person)
$ 2,500
A.............
....................................................................................................................
•mmPERSONAL&ADV INJURY....-(
$.............INCLUD E D
GEN'L
AGGREGATE LIMITAPPLIES PER:
GENERAL AGGREGATE
$ $2,000,000
X
€POLICY P!RO' LOC
JFCr ❑
PROD,U......................................nw,_,....,.,.....,.m.....
-COMP/OP
cTm....AGG
S $2,000,000
O r�tlERr
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
IEa accident)
$
ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per acddent)
$
HIRED ..-'TT NON -OWNED
"FiRbli5iff CA__M'j E'
,n"" - .......
$
AUTOS ONLY AUTOS ONLY
,,.LPer acdt9ent
UMBRELLA LIAB OCCUR
I
EACH OCCURRENCE
$
EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
DED I RETENTIpN $
$
WORKERS COMPENSATION
STATUTE �..;ga OTH
AND EMPLOYERS' LIABILITY YIN......••
,,,,,,,
-'""•••
,,,, .... ••-•
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? �
N/A
-
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
����...........-
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT
$
OTHER
A
Professional (E&O) Liability
X
YOGA1859240-1
10/14/2023
10/14/2024
$1,000,000
A
Professional (E&O) Liability
X
YOGA1859240-1
10/14/2023
10/14/2024
$2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
THIS CERTIFICATE SERVES AS EVIDENCE OF PROFESSIONAL (ERRORS & OMISSIONS) LIABILITY COVERAGE ONLY
Aggregate Limit of Libility for all coverages set forth above: $2,000,000
The City of El Segundo, its officers, officials,
employees, agents, and volunteers --
350 Main Street
El Segundo, CA 90245
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 "
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
ADDITIONAL INSURED ENDORSEMENT
Specified Member: Julia Nicole LeVee
Policy Number: YOGA1859240-1
Endorsement Effective Date: 10/14/2023
It is hereby agreed and understood that the person(s) or entity(ies) listed below is/are included as
Additional Insured(s) underthe combined Professional/General Liability policy number referenced above,
but only with respect to claims or damages arising solely out of professional services rendered by the
Specified Member:
The City of El Segundo, its officers, officials, employees, agents, and volunteers --
350 Main Street
El Segundo, CA 90245
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
Date:
BY:
Authorized Representative
Alliant Insurance Services, Inc.
CALIFORNIA INSURANCE IDENTIFICATION CARD
T'Ms cerfifies thal the Pnsured shown below hol& an automobile fiabifity policy Issued f,:ry
Amiica Muhial Tinsuraince Company The coverage provFded by thB poficy meets the
rinkfirnurn fiibiifi y lirnits prem ibed by law, NA11C # 19976
THIS P01...,.I.CY l)4EE'.PS THE REQU.I.REMENTS OF CAI F.- FORN FA
STAf,[.JTE:S SECTIONS 1(3056 OR 16'500.5.
SOUTHERN CALIFORK.F.A O.FF'..J..CE
1. 8'77 97 2 6 4 2 2
IM40111121011
Amica Mutual Insurarice Company
CORPORATE OFFJCE„ ONE HUNDRED AMICA WAY, I.-INC01-N, RI 02865 1166
MAILPO BOX 6008, PROVII)ENCE, RI 02940 6008
SERVICING OFFICE
SOUTHERN CAI.. FORNIA. OFFICE
3200 Park CenteT Dnive, Sube 650
Costa Mesa., CA 92626
1 877 972 6422
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:
(U 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 #
eI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
loy 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
Signature ant p_ s or the agreement will automatically become void. immediately
comply with those ovis�on Date 9/21 /23
Print Name Julia LeVee
Agreement for.
ilia LRV&
Dated: 10 ance Approval;.
'Neviewed •�CII� MI IIMII IIII�I