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PROOF OF INSURANCE (2024 - 2024) CLOSED'— 1 0 DATE (MM/DD/YYYY) `C"R " CERTIFICATE OF LIABILITY INSURANCE 2/9/2024 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. 1.111,111, 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 GUN I AG I NAME: Gabriel Stubin Western Republic Insurance Services (A/C.No Ext : 714.536.0500EWAIL gpVc, No); 19900 Beach Blvd ADDRESS; gahc@w6nsur ncc.cona Suite Fl INSURER(S) AFFORDING COVERAGE NAIC # Huntington Beach CA 92648 INSURER A : PHILADELPHIA IND INS CO 18058 INSURED INSURER B : PHILADELPHIA IND INS CO 18058 Sergiu Boerica DBA: Jaguar Tennis Academy INSURER C 'T INSURER D INSURER E EL SEGUNDO CA 90245-4013 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. LTR TYPE OF INSURANCE INSD MyyD POLICY NUMBER (MMIDDNYYY) MMIDD/YYW LIMITS www " . COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR 'Rem (Eo occurronce $ 100,000 �_ MED EXP (Any one person) $ 5,000 A -� Y PHPK2464190 09/11/2023 09/11/2024 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JPE LOC - 2,000,000 PRODUCTS-COMPIOPAGG $ OTHER: $ _. UMIT AUTOMOBILE LIABILITY (Ea radorrtll ` $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS - HIRED NON -OWNED Frsraci:Idr+nl)A $ AUTOS ONLY AUTOS ONLY ... ......®. UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIE1QRMARTNERIEXECUTIVE ❑ N /A E.L.. EACH ACCIDENT $ FFICEWMEMBER EKCLUDED7 .. (Mandatary in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Accidental Medical Coverage PHPA117263 09/11/2023 09/11/2024 $25,000 www DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. The certificate holder is named as additional insured per the PI-AS-009 (04/04) endorsement. CERTIFICATE HOLDER CANCELLATION! SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of El Segundo, its officers, officials, employees, agents and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. volunteers 401 Sheldon Avenue '.. AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 (fp jyr j,�( S{w{y ©1988-2015 ACORD CORPORATION. All rights reserved,. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD PERSONAL AUTOMOBILE POLICY AMENDED COVER PAGE SERGIU BOERICA aw�=wiiiio WAWANESA INSURANCE PO BOX 82867 SAN DIEGO CA 92138-9492 TELEPHONE: 800-640-2920 Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of 32400050 34883441-1 From Sep 24, 2023 to Mar 24, 2024 the Named Insured as stated herein Thank you for your continued business with Wawanesa General Insurance Company ("Wawanesa Insurance"). We appreciate the opportunity to provide you with quality coverage and peace of mind knowing that we strive to provide the most dependable coverage at the lowest price possible. Please review your amended Policy Declaration. This Declaration supersedes any previous declaration bearing the same policy number for this policy term. The amended Declaration is effective Oct 06, 2023. As requested by Sergiu Boerica, the following items have been amended: Vehicles Coverages Policy Information You should also carefully review your coverage limits for Bodily Injury Liability and Property Damage Liability to ensure they are appropriate for your lifestyle, income, and risk tolerance. If you are found legally responsible for damages which exceed your Liability coverage limits, personal assets such as your savings or even your home could be at risk. Industry organizations and consumer groups recommend limits higher than what the law requires. By accepting this Policy and the Declaration pages you consent to be legally bound by the provisions of the policy, including the coverage limits, options and endorsements. Important Information (This page is part of your Policy Declaration): If you are responsible for the payments due on this policy, please refer to the invoice statement (enclosed or mailed separately). The invoice statement also includes additional payment information, such as our flexible payment options. Questions? Our knowledgeable Customer Service Representatives will be happy to assist you with any questions you may have after reviewing your information. Did you know? For more information regarding our products and services, visit our website at wawanesa.com. You can also submit changes to your policy, report a claim, or receive an insurance quote in minutes. Thank you for being a valued customer. Earning Your Trust Since 1896 Oct 05, 202316:30 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company PERSONAL AUTOMOBILE POLICY Amended Declaration effective AMENDED DECLARATION Oct 06, 2023 JffSVJVqCe Supersedes any previous declaration bearing " the same policy number for this policy period. Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of 32400050 34883441-1 From Sep 24, 2023 to Mar 24, 2024 the Named Insured as stated herein Named Insured's Phone Number: 310-227-4405 Named Insured's Email Address: jatbiz84@gmail.com Your amended 6 month premium is $748.69. Refer to the breakdown of premiums below. The change in premium for the remainder of the policy period is $162.72. Description of Owned Vehicle(s) _..._._._. _WW_ ......_. ... __.._...... Vehicle Year Make Model Vehicle Identification Number Premium per Vehicle($) _ ............... ..._..,-_ .............. _ ........ __..._.._...._ ... 1 2002 For _ d EXCURSION LIMITED $295.02 ......... ......... ...... .. _. 2 2011 Mazda CX-7 I TOURING $453.67 ------- Premium Subtotal for Vehicle s es $748.69 Insurance is provided only with respect to the coverages for which a Premium is stated, subject to all conditions of the policy. Coverage and Limits of Liability Premiums per Vehicle ($) See Policy for Coverage Details 1 2 Bodily Injury Liability per person/$30,000 each occurrence 131.28 124.53 �$15,000 Property Damage Liability $10,000 each occurrence 107.34 98.02 Comprehensive $500 deductible 28.72 Collision $500 deductible 148.71 Uninsured/Undednsured Motorists Protection $15,000 per person/$30,000 each occurrence 50.27 ..... 52.01 —.. Uninsured Motorists Property Damage $3,500 each occurrence 6.13 Uninsured Motorists Collision Deductible Waiver 1.68 Total Premium Per Vehicle ($) 295.02 453.67 All premiums listed are for the full 6-month term. Oct 05, 2023 16:30 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company PERSONAL AUTOMOBILE POLICY AMENDED DECLARATION Supersedes any previous declaration bearing the same policy number for this policy period. Amended Declaration effective Oct 06, 2023 SERGIU BOERICA WAWANESA INSURANCE PO BOX 82867 SAN DIEGO CA 92138-9492 Now TELEPHONE: 800-640-2920 Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of 32400050 34883441-1 From Sep 24, 2023 to Mar 24, 2024 the Named Insured as stated herein Vehicle Rating Information Chart ............._ ................ ...... .......... _.... Vehicle Description Estimated Rated Vehicle Usage Zip Code Discounts # of Traffic # of Chargeable Annual Driver No. Applied (See convictions for at -fault Mileage of Years code definition driver rated on accidents for Used for Licensed below) this vehicle driver rated on Rating this vehicle .......... .................. __. - ...... 2002 Ford 12000 39 Commuting 90241 1, 2, 4 0 0 -5271 ..... .._..... ..... ........ 2011 Mazda 7000 21 Commuting 9I0241 1, 2, 4 0 0 -5271 .._._ ....... Di _ _ __....... scount Codes: 1. Good Driver 2. Multi -Vehicle 3. Mature Driver 4. Loyalty or Affinity Group Important Information Regarding Estimated Annual Mileage: State law requires us to periodically verify the miles you plan to drive annually. Please review the estimated annual mileage for each vehicle listed above. If the amount provided does not reflect your anticipated mileage in the next 12- months, please contact us so we can update your policy. We may ask for additional information to support your estimate. If we don't hear from you, the estimated mileage shown will be used for your upcoming renewal. Depending on the information you provide, we may use a mileage amount different than your estimate to set your upcoming term's premium. Driver(s) Driver Name Principal Operator of Vehicle Number Occasional Operator of Vehicle Number ...... ..... g 1 . _. . Ser _._.. _. 2 iu Boerica ... _............ llliilqli 2 Exclusion of Named Driver(s) Excluded Driver(s) Relationship to Insured Not Related Child POLICY AND ENDORSEMENTS THAT ARE PART OF YOUR CONTRACT WITH US. REMAIN IN EFFECT (Refer to prior Policy Packet(s) for documents not attached.): Community Service Statement (CSS), California - Designated Additional Person To Receive Notice of Cancellation or Nonrenewal (CADAPE 09 21), Personal Auto Policy - California (CAPAP 09 21), Available Coverages & General Coverage Descriptions (CACOV 09 21), California Notice of Designated Additional Person to Receive Notice of Cancellation (CADAP 09 21), Disclosure of Fees - California Auto (CADCFA 04 22), Minimum Liability Coverage Limits and Available Discounts (CADIS 09 21), Important Information - Price Increase Notice (RCN 05 23), Vehicle Identification Cards (VID), Vehicle Identification Cards (VID) Oct 05, 2023 16:30 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company SERGIU BOERICA WAWANESA INSURANCE PO BOX 82867 SAN DIEGO CA 92138-9492 TELEPHONE: 800-640-2920 Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of 32400050 34883441-1 From Sep 24, 2023 to Mar 24, 2024 the Named Insured as stated herein Important Information - Consumer Services - California Because of the complicated nature of the insurance business, there may be times when you will have questions regarding your coverage or the premium charged, or a problem may arise with your policy. If this occurs we urge you to contact our Customer Service Department to answer your questions or resolve your problem. If after this you are still not satisfied, you may contact the following state agency: California Department of Insurance, Consumer Services Division, 300 South Spring Street, South Tower, Los Angeles, California 90013 Toll free number: 1-800-927-HELP Website: www.insurance.ca.gov YOUR PRIVACY RIGHTS. We use information about you to provide you with insurance and adjust claims. We collect this information from you as well as from other sources. In certain circumstances, we may disclose this information to third parties without your consent. You have the right to access and correct any information about you that we collect. For more details about our privacy practices, please visit us at www.wawanesa.com. To receive a copy of our full privacy notice call us toll -free at 1-800-640-2920, or write to us at the address shown above. Visit wawanesa.com/online to view information about your policy or contact Customer Service for additional assistance. Online Service: Make payments, Our helpful agents are available: Fax: 619-285-2711 check billing activity, update policy Monday to Friday 7.30 am - 7:30 pm Mail: PO Box 82867 details, or view claims information. and Saturday 8:00 am - 4:30 pm San Diego, CA 92138-9492 wawanesa.com/online Phone: 800-640-2920 Email: service.us@wawanesa.com Oct 05, 2023 16:30 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company 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. 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 area. Carrier Name of Agent Policy Number Expiration Date 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 1 must immediately comply ith thos g Datvislons o; the agreement will automatically become void. e Signature of Applicant Print Name Agreement for: Dated Reviewed by: