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PROOF OF INSURANCE (2024 - 2025)CERTIFICATE OF LIABILITY INSURANCE 01/11/2024 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, theITpolicy(ies) must have ADDITIONAL INSURED provislons or be e 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 riahts to the certificate holder In lieu of such endorsement(s). ADMINISTRATOR ACT cci,al L-' Ilt. DgarTnlen( CONt iy ._,,.. Hub International Insurance Services, Inc _ ,. .. ......... .. e ,.., ,-- PHONE (925)609-6500 FA1t (925) 609-6550 3000 Executive Pkwy, #300 EAnL ;trciaC� wcntilrlalIntcmaaiaPlal cOTro .. ._._.. _...., 4"t ReRi(,S) AFFORDINO C'OV RAC,,E ... San Ramon CA 9`� 583 INS uRERA C"+,a�re5 lnsurIca Lo)pg74riy. ,.._ _ .3993�._..,....e INSURED INSURER B : Anna Giannotis - , INSURER D :. pNSLIR:ER.E' Los Angeles CA 90034 INSURERF; COVERAGES....... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE AND INSURED MEMBER ENDORSEMENT LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE COVERAGE PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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 CLAINIS. ..._ , 1YPE OF INSURANCE . WS'URED MEMBER . NUMBER ,.. ...,E EC _ ,.,_ .. „.... ....... � .... ...... INSR E BER END'[ NU'MBE'R COVERAGE EFFECr1VEiEKPpRAT1N DATE r LIMITS LTR 24008738 OI/1U2024/ EACHDCCURR5.NCC s 1,4 A --. CLAIMS -MADE �/ OCCUR 01/06/2025 DAtOAk?ETOAENIL0 COMMERCIAL GENERAL LtABILITY e !fdFh.IgSES.tEa,or.'mot*04eJ S 1,,00(000...... ItLUCk; Ar try a: -yarn S 5p000 _O 4YViNJURR S 1,000,000 Tt 1 PERSONAL A . GENERAL AGGREGATE APPLIES ; GENERAL, AGGREGATE _ s 2,000,000 SEPARATELY TO THE NAMED INSURED --- „AS PER ATTACHED ENDORSEMENT ' Pr30LFUCTS _ COEIPfOP r±GG ,S Z,O01.1 OOO T1523.01 x f LIQUOR LIABILITY PER ' g N/A `OCCURRENCE (AGGREGATE INCLUDED IN GENERAL LIABILITY AGGREGATE) MASTER POLICY NUMBER: 103 GL 0212472-01 EFFECTIVE DATE 2024-01-01 EXPIRATION DATE: 2024-12-31 12:0I A.M. standard Time at your i Mailing Address. DESCRIPTION OF OPERATIONS f LOCATIONS x VEHICLES 1ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) The certificate holder is included as Additional Insured as per endorsement T5409-0118, This insurance is Primary and Non -Contributing as per endorsement CG2001-1219. The insurance company waives rights of recovery as per endorsement CG2404-1219. The Insured Member Endorsement cannot be cancelled by the insurance company as per endorsement T1523-0111. Event Type: Instructor Event Locations: 300 E. Pine StJ 641 Cali€omia St. El SEgundo CA 90245 CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street I AUTHORIZED REPRESENTATIV— EI Segundo CA 90245 1 Liability Insurance Policy — Member Endorsement Special Event Liability Group Insurance Trust wtyw.eyotrt,sr surd orn This is to certify that the policy of insurance listed below has been issued and this endorsement adds the Named Insureds as Members for the event and dates indicated on this Member Endorsement. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this endorsement may be issued or may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such master policy. Producer Name: Hub International Insurance Services, Inc Mail Address: 3000 Executive Pkwy, #300 City: San Ramon State: CA Zip: 94583 Phone##: (925) 609-6500 FaxE#: (925) 609-6550 Email: specialevent@hubinternational.com Website: www.eventinsure.com License State: CA License Number: 075776 First Named Insured/Member Name: Anna Giannotis Mail Address Member Endorsement Number Member Endorsement Effective Date Member Endorsement Expiration Date Event Description Drama, Musical or Theatrical Insurance Company Colony Insurance Company Master Policy Number 103 GL 0212472-01 City: Los Angeles State: CA Zip: 90034 24008738 01/11/2024 01 /06/2025 12:01 A M_ Standard Time at your Mailing Master Policy Effective Date 2024-01-01I Master Policy Explration Date 2024-12-31 Endorsement Premium $ 106.00 Broker Fee 10.00 Processing Fee 15.00 State Tax 3.18 Stamping Fee 0.19 Total Cost $ 134.37 Member Endorsement Limits: Each Occurrence $ 1,000,000 Personal & Advertising Injury 1,000,000 General Aggregate 2,000,000 Products & Completed Operations 2,000,000 Damage to Premises Rented to You 1,000,000 Medical Payments 5,000 Liquor Liability Each Occurrence N/A If a Liquor Liability Each Occurrence limit is displayed, then Liquor Liability is subject to the General Aggregate Limit shown above. Liability Deductible $ 0 Master Policy Number 103 GL 0212472-01 Member Endorsement Number 24008738 Date 01/11 /2024 Authorized Representative Type of Insurance Commercial General Liability Occurrence Form CG 00 0104 13 Forms and Endorsements: Number CAPRNOTICE-0911 D2-0120 ILP001-0104 PRIVACYNOTICE-0820 U094-0423 SIGCIC-0817 DCJ6550-0921 0001-1004 DCJ6553-0702 U411-0615 CG0001-0413 CGO033-0413 CG2412-1185 UCG2175-0121 CG2001-1219 CG2010-0413 CG2037-0413 CG2109-0615 CG2116-0413 CG2149-0999 CG2153-0196 CG2167-1204 CG2196-0305 CG2244-0413 CG2404-1219 IL0021-0908 T1007-0507 T1065-0409 T1523-0111 T1944-0124 T4326-0113 T5152-0117 T5153-0117 T5380-0817 T5407-0118 T5408-0118 T5409-0118 Title California Notice — Premium Refunds Important Notice (CA) US Treasury Department's Office of Foreign Assets Control ("OFAC") Advisory Notice Notice of Insurance Information Practices Service of Suit Signature Page Common Policy Declarations Schedule of Forms and Endorsements Commercial General Liability Coverage Part Declarations Liquor Liability Coverage Supplemental Declarations Commercial General Liability Coverage Form Liquor Liability Coverage Form Boats Terrorism Exclusion Primary and Noncontributory— Other insurance Condition Additional Insured -Owners, Lessees or Contractors -Scheduled Person or Organization Additional Insured -Owners, Lessees or Contractors -Completed Operations Exclusion -Unmanned Aircraft Exclusion -Designated Professional Services Total Pollution Exclusion Endorsement Exclusion -Designated Ongoing Operations Fungi or Bacteria Exclusion Silica or Sifica-Related Dust Exclusion Exclusion -Services Furnished by Health Care Providers Waiver of Transfer of Rights of Recovery Against Others to Us Nuclear Energy Liability Exclusion Endorsement (Broad Form) Exclusion -Concert Liability Common Policy Conditions Separation of Insureds -Insured Members and Reporting Endorsement Additional Insured -Volunteers Conditional Liquor Liability Endorsement Exclusion -Designated Operations Exclusion -Rides Additional Insured -State or Governmental Agency or Subdivision or Political Subdivision -Permits or Authorizations Limits of Insurance -Designated Project or Premises Cross Suits Exclusion Additional Insured -Designated Person or Organization (LIST CONTINUED ON FOLLOWING PAGE) 0 v v rn rn to N 0 Master Policy Number 103 GL 0212472-01 Member Endorsement Number 24008738 Date 01/11/2024 Forms and Endorsements (Continued): Number Title T5531-0119 Exclusion -Designated Activities T5532-0119 Additional Insured -Designated Person or Organization T5533-0119 Additional Insured -Managers or Lessors of Premises T8022-0820 Alaska Policyholder Notice 0002A-0916 Minimum Earned Premium U009-0310 Aircraft Products and Grounding Exclusion U016-0621 Athletic or Sports Participants Exclusion U018-0520 Exclusion -Communicable Disease, Virus or Bacteria U048-0310 Employment -Related Practices Exclusion U1010-0819 Exclusion-Cyber Injury, Electronic Data, and Confidential or Personal Information U1338-1221 Exclusion -Poly -and Perfluoroalkyl Substances (PFAS) U1396-0223 Exclusion -Hired Auto(s) Liability U173AS-0708 Cancellation U175-0608 Multiple Coverages Limitation U232-0104 Exclusion -Punitive, Exemplary or Multiple Damages U266-0510 Exclusion-USL&H, Jones Act or Other Maritime Laws U276-0310 Exclusion -Breach of Contract U466-0212 Exclusion -Lead U467-0212 Exclusion -Asbestos U684-0511 Exclusion -Abuse or Molestation State Surplus Lines Notification CALIFORNIA DISCLOSURE: Worldwide Facilities, Inc (WWFI) may be charging you a brokerage fee for providing the basic services set forth herein. The amount of the mutually agreed upon brokerage fee, if any, is the amount included on our invoice_ The general brokerage services we perform include, but are not limited to, searching our relevant market(s) for appropriate combination(s) of price, coverage and security for a particular risk. WWFI may also be entitled to receive compensation, directly or indirectly, from the insurer that accepted and bound your business, even when you have been charged a brokerage fee.The above disclosures are required by Section 1623 of the Insurance Code of the State of California when a wholesale intermediary broker transacts insurance with, but not on behalf of, an admitted insurer. Worldwide Facilities, Inc, in the interest of transparency, includes this disclosure on transactions with both admitted and non -admitted carriers where brokerage fees are involved.Please review the above quotation/binder carefully; terms and/or conditions may differ from those requested in your submission. In addition to the above mentioned exclusions, the policy contains other standard exclusions; specimen policies are available upon request. Terms herein are summarized for use by a licensed broker and should not be submitted in this format to the applicant. Please call with any questions.This quotation/binder is subject to all terms and conditions of the policy to be issued. The quotation/binder shall be terminated and voided by delivery of a policy to either the insured, his agent or representative. The coverage will remain in effect for the term indicated unless cancelled by the insured, WWFI or the Company, via written notice.This quotation/binder is a privileged document and shall not be released or assigned in whole or in part to any other person or entity without the written consent of WWFI, endorsed hereon. 0 Q E5 rn rn 0 Master Policy Number 103 GL 0212472-01 Member Endorsement Number 24008738 Date 01/11/2024 Full Named Insured Schedule First Named Insured: Anna Giannotis Master Policy Number 103 GL 0212472-01 Member Endorsement Number 24008738 Date 01/11/2024 Master Policy Number 103 GL 0212472-01 Member Endorsement Number 24008738 Date 01/11/2O24 Additional Insured Schedule Additional Insured Name: City of El Segundo Mail Address: 350 Main Street, EI Segundo, CA 90245 Additional Insured Type: Property Owner, Manager, Lessor of Premises r ff v M rn N3 0 0 Master Policy Number: 103 GL 0212472-01 Member Endorsement Number: 24008738 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY -- OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and 0 rn M to N O CG 20 01 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: 103 GL 0193585-02 Member Endorsement Number: 24008738 COMMERCIAL GENERAL LIABILITY CG 24 0412 19 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): As required by written contract with the Named Insured that is executed by the parties to the contract prior to the commencement of work that is called for in the contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 C- 0 Cr v rn rn co N O THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IF CAREFULLY. SEPARATION OF INSUREDS - INSURED MEMBERS AND REPORTING ENDORSEMENT T Master Policy Number: This endorsement modifies insurance provided under the following: 103 GL 0212472-01 COMMERCIAL GENERAL LIABILITY COVERAGE PART Member Endorsement Number: LIQUOR LIABILITY COVERAGE PART 24008738 A. SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, and COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY, 2. Exclusions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM, and SECTION I — LIQUOR LIABILITY COVERAGE, 2. Exclusions of the LIQUOR LIABILITY COVERAGE FORM are amended and the following added: This insurance does not apply to: Unreported Events "Bodily injury", "property damage", "personal and advertising injury" or "injury" arising out of any "Insured Members)" that you have not reported in the Policyholder's Bordereaux, subject to SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Reporting Provisions added in item E. below. However, this provision does not apply in the event of an unintentional error or omission in not reporting an "Insured Member" in the Policyholder's Bordereaux if such "Insured Member" received a Certificate of Insurance and paid the premium prior to the "bodily injury", "property damage" or "personal and advertising injury' or "injury" that resulted in a claim or "suit". B. SECTION 11 — WHO IS AN INSURED, 1. a. of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY COVERAGE FORMS, is deleted and replaced with the following: a. An individual, you and your spouse are a named insured, but only with respect to your conduct as an "Insured Member" named on the Certificate of Insurance referenced in item C. below. C. SECTION II — WHO IS AN INSURED of the COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY 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. SECTION IV — COMMERCIAL GENERAL LIABILITY and LIQUOR LIABILITY CONDITIONS, 7. Separation Of Insureds 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 T1523-0111 Page 1 of 3 0 Cr 0 m rn 0 0 6 rn b. separately to each "Insured Member" against whom claim is made or "suit" is brought. N 0 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. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS and SECTION IV —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 Policyholders 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 Policyholder's Bordereaux, you must include a copy of the Certificate of Insurance issued evidencing the "Insured Member's" 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". T1523-0111 Page 2 of 3 0 Cr rn F. SECTION IV — COMMERCIAL GENERAL LIABILITY and SECTION IV — LIQUOR LIABILITY N CONDITIONS, 5. Premium Audit, are deleted and replaced with the following: 0 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 Members" 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. T1523-0111 Page 3 of 3 Master Policy Number: 103 GL 0212472-01 Member Endorsement Number: 24008738 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 ame Of Addition City of El Segundo 350 Main Street E1Segundo Or O SCHEDULE CA 90245 I information reauired to complete this Schedule, if not shown above, will be shown in the Declarations, I Section Ii — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(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 omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. T5409-0118 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. C_ 0 Q v rn rn N) N O 103 GL 0212472-01 rn rn IORTANT NOTICE: o MP 1. The insurance policy that you have purchased is being issued by an insurer that is not licensed by the State of California. These companies are called "nonadmitted" or "surplus line" insurers. 2. The insurer is not subject to the financial solvency regulation and enforcement that apply to California licensed insurers. 3. The insurer does not participate in any of the insurance guarantee funds created by California law. Therefore, these funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. 4. The insurer should be licensed either as a foreign insurer in another state in the United States or as a non -United States (alien) insurer. You should ask questions of your insurance agent, broker, or "surplus line" broker or contact the California Department of Insurance at the toll -free number 1-800-927-4357 or internet website www.insurance.ca.gov. Ask whether or not the insurer is licensed as a foreign or non -United States (alien) insurer and for additional information about the insurer. You may also visit the NAIC's internet website at www.naic.org. The NAIC—the National Association of Insurance Commissioners —is the regulatory support organization created and governed by the chief insurance regulators in the United States. 5. Foreign insurers should be licensed by a state in the United States and you may contact that state's department of insurance to obtain more information about that insurer. You can find a link to each state from this NAIC internet website: https.-//naic.org/state—web—map.htnL 6. For non -United States (alien) insurers, the insurer should be licensed by a country outside of the United States and should be on D-2-0120 Page I of 2 103 GL 0212472-0` 0 Cr R rn m the NAIC's International Insurers Department {IlD) listing of o approved nonadmitted non -United States insurers. Ask your agent, broker, or "surplus line" broker to obtain more information about that insurer. 7. California maintains a "List of Approved Surplus Line Insurers (LASLI)." Ask your agent or broker if the insurer is on that list, or view that list at the internet website of the California Department of Insurance: www.insurance.ca.gov/0I-consumers/120-company/07- lasli/lasli.cfm. 8. If you, as the applicant, required that the insurance policy you have purchased be effective immediately, either because existing coverage was going to lapse within two business days or because you were required to have coverage within two business days, and you did not receive this disclosure form and a request for your signature until after coverage became effective, you have the right to cancel this policy within five days of receiving this disclosure. If you cancel coverage, the premium will be prorated and any broker's fee charged for this insurance will be returned to you. D-2-0120 Page 2 of 2 CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIL 25968 ANNA G LUNA one LOS ANGELES CA 90034-5442 ANNA G LUNA USAA CASUALTY INSURANCE COMPANY allcy Number Effective Date Expiration 0854 54 07C 7101 2 1 02/07/24 08/07/24 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. ------------------- -fi -a c k---------------- California Evidence of Financial Responsibility Keep this card. IMPORTANT: The California Financial Responsibility' Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of 0 financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, d impoundment or license suspension. Additional copies available at usaa.com CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIAL 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 onder per*lty of pttjtxy uodor lhm^ laws c>I CraLlcuma orlu -Lf tier I-jilowing n 11,i C-C io ssu tpy Mo. Director al indusl;rial ReNtinns as proWded for by Lobor Codff- _§ 37fj0 for the rpedo-rmance of ho wort: m' for h ttx; agoement wilul thu '01-V of El Segundo - Policy No. of I'm work tot winch the agreement wizh the: City of El Seguqdu is exc-cuLed, My lmor�kcxs' cul"pellsob-'m 1s;ulancu- cam'ez and pcj numbut are: carn":A PoFcy Nurnb�z Eypira-,,on Dme `!urns of Aqpiil M )011-e I I lZ; �,' coffify thut. m Hit: perfortnalico of isle work. '."u'luath 41 Lhe acrpi�.mp;v Wr:'] th'r ('rIy 'M F1 segunp'..'% � wM r'^v ornp4oy any PQT�l it) �'Iry lannur i* as to ix.'Cumc 11w .kum' ,ar Cafilnm!�I' awl a.qroe that, if i shou'L- L'=urno sub-pd la Ulu crjrnpum-�a4jorl pmvti.-Jnm; M Labs Cook, r 37f)0 V must 7mmediate-v rorr* w4h ,how =vjs�,AS or VI C elgi'0�=Ml mMl 00orn4tiwily loccume Void. Signaltyfk r7z AprA�11*q L) Print Name Agre,pmont for Reviewed by: