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PROOF OF INSURANCE (2024 - 2024) CLOSEDC CERTIFICATE OF LIABILITY INSURANCE 'CE I QM4/2023 THIS CERTIFICATE is L9SUED AS A MATTER OF INFORMATION ONLY AND GO. NFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFNCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOkf', THIS CERTIFICATE OF INSURANCE DES NOT CONSTfTiR A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, .AND TIME CERTIFICATE HOLDER.. IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED, the ollelles) must' haws ADD INrNSURED slons or be endorsed. If SUBROGATION IS WAIVED, btCt to the tuts and conditions of the poll cy, certain policies may rerNulr�w srN +Isr A statement on this certificate does not confer rig to the certificate holder In Ilea of such endor menks). PRODUCER K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 PHONE 1 �00 328-2317 1-260-459-5502 ;MA. info@eventlnsurance-W-com I ISSRED 2001491819 CP# 647 NSURER A. Markel Insurance t;om _ 7Otl/ V N e+s<rRsr a: atalle Sir INSURE; C: El Segundo, CA 90245 INSURER D: A Member of the Sports, Leisure & Entertainment RPG RIBURER E: NSUREA F: COVERAGES CERTIFICATE NUMBERNUMBERt 2WO597788 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 INSURANCEI19D ADDL SUOR wvo POLICY NUMBER POUCY'EXP LWTS A X cowAERCIALaENERALLIAaLrrY CLAIMSMADE X OCCUR X X MIFPGODOOM161400 OW17123 OW1724 EACHOCCURRENCE fPREMISSES 5A> ES( O FMMR t�iS -, $1,000,000 $1,000,000 MED EXP (Any ore person) $5,000 '...... PERSONAL A ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $1,000,000 POLICY PROJECT LOC PROFESSIONAL LIABILITY $1,000,000 PGEN'L OTHER: I EGALUABTC PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY BODILY INJURY (Per person) ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per w dderd) HIRED NON -OWNED AUTOS ONLY B AUTOS ONLY LMB OCCUR jEACH OCCURRENCE AGGREGATE EXCESS LIAR CLAIMS -MADE DED RETENTION =K)RIEIS EaPL� SAATIM IABLrrY WA PER TA OTHER ANY PROPRIETORIPARTNER/ r I N E.L EACH ACCIDENr .. .. .. EXE-CUTIVEOFFICFRVEMBER - EXCLUDED? Oftmawy in P" - � EL DISEASE- EA EMPLOYEE —_ _ IPTION OF OPERATE below EL DISEASE- POLICY LIMB PAYNIMS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCR bm-ATOR I (A I01, r tNr mGra ape d nqukrad) Instructor of: Artistic painting, Clay Work and/or pottery, Craft making, Drawing, Sculpting The certificate holder is added as an additional Insured, but only for Ilablilty camed, in whole or In part, by the acts or omissions of the reamed insured. Primary and Noncontributory is added via form MGL 1574 Waiver of Transfer of Rights of Recovery Against Others to Us is added via form CG2404 Syr r • r 911CC0a1aA9!*K City Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 350 Main St EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH El Segundo, CA 90245 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUrHORIZED RE, ATME [ yl~, ..�,[4NI.7 ia�e➢,➢r�as;�➢W9�+rd.r-+I�, ,rd�� a➢',raWr,lre{ rr� ➢m ° -«r Coverage is only extended to U.S. events and activities. NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (20%03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: M1 RPG000000O161400 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II — Who Is An Insured Is amended to Include as an additional Insured the person(s) or organization(s) shown in the schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omisslons or the acts or omisslons of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The Insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured Is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits of Insurance: If coverage provided to the additional insured Is required by a contract or agreement, the most we will pay on behalf of the additional Insured Is the amount of Insurance: 1. Required by the contract or agreement; or 2. Available under the applicable t.imlts of Insurance shown In the Declarations; whichever Is less. This endorsement shall not increase the applicable Limits of Insurance shown In the Declarations. CG 20 26 0413 0 Insurance Services Office, Inc., 2012 Page 2 of 2 PIARKEL INSURANCE COMPANY III NLUM MEMBER CERTIFICATE CERTIFICATE NUMBER: 200286621410/24/2023 DATE: October 24, 2023 THIS CERTIFICATE REPRESENTS INSURANCE PROVIDED IN ACCORDANCE WITH THE FOLLOWING: MASTER POLICY NUMBER: Mi RPG000000O161400 FIRST NAMED INSURE D (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, Tip Code): Natalie Strong El Segundo, CA 90245 Effective Date: 09/17/23 at 12:01 a.m. Standard Time at the address shown above. Expiration Date: 09/17/24 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 Fork 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 De cr on Of Oper Description Of Operations: Instructor of: Artistic Premises And Operations Location No. Address Refer to MGL 1576 Commercial General Liability General Aggregate: Products/Completed Operations Aggregate: Personal And Advertising Injury: Each Occurrence: Damage To Premises Rented To You: Medical Expense: Premises, And Clay work and/or f Limits Of Insurance $5,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000 $5,000 rations , Craft making, Operations Any One Person Or Organization Any One Premises 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. Bodily Injury to Participants Professional Liability Limit Of Insurance $1,000,000 Each Occurrence $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 thi s Member 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: October 24, 2023 By: /a X% Date AUTHORIZED REPRESENTATIVE MCGL 1002 07 21 Page 2 of 2 GDOYA240129 0 002 004 010092 California FARMERS 3{ Evidence of Liability Insurance INSURANCE KEEPWITHVEHICIE (= Namedlnsured(s): Policy Number:1574443475 Effect";1 /27/2024 S Natalie Strong Expiration: 8/5/2024 N = NAIc Number: 21687 m YaurAgent: Underwriting Company: Don Harrison Mid -Century Insurance Company Agent Phone: (310) 371-9100 6301 Owensmouth Ave. Woodland Hills, CA 91367 Phone: 1-888-327-6335 ` Fold here i Vehicies(s): Registered Owner(s): 2011 Nissan Leaf Electric SD Patrick Strong 2018 Mazda Cx-5 4D 2Wd Touring Patrick Strong California Evidence of Liability Insurance Natalie Strong Your Agent: Don Harrison Agent Phone; (310) 371-9 100 California Evidence of Liability Insurance S 1. Named Insured(.) NatalleStrong I YourAgent: Don Harrison - Agent Phone: (310)371-9100 i FARMERS INSURANCE Policy Number:157448475 Effective: 1/27/2024 Expiration: 8/5/2024 NAIL Number: 21687 Underwriting Company: Mid -Century Insurance Company 6301 Owensmouth Ave. Woodland Hills, CA91367 Phone: 1-888-327-6335 n c Fold here Vehicies(s); Registered Owner(s): ro 2011 NissanLeaiElectric5D Patrick Strong -------- - - -- — g 2018 Mazda U-5 4D 2Wd Touring Patrick Strong iln1� cuthere FARMERS 7 = California INSURANCE Evidence of Liability Insurance DMVREGISTRATIONCOPY z Policy Number:157448475 s N s)c Effedlve:1/27/2024 - - Expiration: 8/5/2024 Natal le Strong NAIL Number: 21687 Underwriting Company: Your Agent: Mid -Century Insurance Company Don Harrison 6301Owensmouth Ave. AgentPhone:(310)371-9100 Woodland Hills, CA91367 Phone: 1-888-327-6335 Fold Isere Vehides (s): Registered Owner(s): 11 Nissan LeafElectfieSD Patrick Strong _. . 2018Mazda CxS4f32WdTouring Patrick Strong FARMERS INSURANCE DMV REGISTRATION COPY I Policy Number: 157448475 Effective: 1 /27/ 2024 Expiration: 8/5/2024 NAIL Number: 21687 Underwriting Company: Mid -Century Insurance Company 6301 Owensmouth Ave. Woodland Hills, CA91367 Phone: 1-888-327-6335 n c Fold hereCD --- Vehicles(s): Registered Owner(s): 2011 Nissan Leaf Electric SD Patrick Strong Touring Patrick Strong m m cut here Fold here Fold here 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. U 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 Name of Agent Policy Number Expiration Date Phone # o 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 su 'ect. to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply witr he agreement will automatically become void. .. ant Signature of Applicant .. sort Date Print Name Agreement for: Dated: Reviewed by: