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PROOF OF INSURANCE (2024 - 2025) CLOSEDCERTIFICATE 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)
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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.
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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
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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
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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
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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
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b. separately to each "Insured Member" against whom claim is made or "suit" is brought. N
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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
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F. SECTION IV — COMMERCIAL GENERAL LIABILITY and SECTION IV — LIQUOR LIABILITY
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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.
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103 GL 0212472-01
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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`
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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
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Print Name
Agre,pmont for
Reviewed by: