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PROOF OF INSURANCE (2024 - 2025)ACCME> CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrrM) 10% � 1 03/28/2024 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 poiicy(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 K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne, IN 46804 INSURED Victoria K Samia El Segundo, CA 90245 A Member of the Sports, Leisure & Entertainment RPG COVERAGES MM - Fitness Instructors 1-800-506-4856 INSURER(S) AFFORDING COVERAGE INSURER A: Markel Insurance Company INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: CERTIFICATE NUMBER: 000065595 1-260-459-5502 NAIC M 38970 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, W$k TYPE OF INSURANCE AO L SUB POLICY NUMBER LTR INSD WVD P Y LIMITS (MMIOiNYFFF _ ._ M( MIDD/YYYY;), _ .......... .w................_ A X COMMERCIAL GENERAL LIABILITY X M1RPG0000000131600 03l28I2024 03128/2025 EACH OCCURRENCE $1,000,000 CLAMS- OCCUR 08:02 PM EDT 12:01 AM rT0-RE"0 MADE I x I PREMISES Ea Occurrence)$1,000,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERA- AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOPAGG '.. $1,000.000 POLICY PRO- LOC �JECT PROFESSIONAL LIABILITY $1,000,000 ._.. OTHER: $1,000,000 PARTICIPANTS AUTOMOBILE LIABILITY M R I N ffI5Zi-NMrE-LTWfT— fEa accident ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED BODILY INJURY (Per accident) ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB ..-... CLAIMS -MADE AGGREGATE .. DEC) RETENTION WORKERS COMPENSATION AND NIA STATUTE OTHER Li EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERI YIN E.L. EACH ACCIDENT E(ECUTIVEOFFICERIMEMBER ❑ E.L. DISEASE- EA EMPLOYEE EXCLUDED? (Mandatory In NH) E.L. DISEASE - POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Certified Instructor of: Aerobics,Pilates The Certificate holder is added as an additional insured, but only For liability caused, in whole or in part, by the acts or omissions of the named insured. City of El Segundo 350 Main St El Segundo, CA 90245 Owner/Manager/Lessor of Premises LytV L9 a el LI I Leis THE EXPIRATION DATE THEREOF„ NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Coverage is oniy 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 Slate of Texas ACORD 25 (2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MIRPG0000000131600 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 FNamre Of Additional Insured Persons Or Or anization s of EI Segundo Main St El Segundo, CA 90245 Named Insured: Victoria K Sarnia Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section If — 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 omissions or the acts or omissions 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 Limits 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 © Insurance Services Office, Inc., 2012 Page 1 of 1 MARKEL INSURANCE COMPANY MARKEC' MEMBER CERTIFICATE CERTIFICATE NUMBER: U00065594 DATE: 03/28/2024 THIS CERTIFICATE REPRESENTS INSURANCE PROVIDED IN ACCORDANCE WITH THE FOLLOWING: MASTER POLICY NUMBER: MlRPG000000O131600 ...-.... .... FIRST NAMED INSURED (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, County, State, Zip Code): Victoria K Samia Effective Date: 03/28/2024 at 08:02 PM EDT Expiration Date: 03/28/2025 12:01 AM This replaces prior Certificate Number: Plan Administered By K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 Contact Information Name: MM - Fitness Instructors 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 By Mail K&K Insurance Group, Inc. 1712 Magnavox Way P.O. Box 2338 Fort 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 3 De_.........................._.._. w Description Of Operations, Premises, And Operations Description Of Operations: Certified Instructor of: Aerobics, Pilates Premises And Operations: Location No. Address Operations Refer to MGL 1576 Limits of Insurance Commercial General Liability General Aggregate $5,000,000 Products/Completed Operations Aggregate $1,000,000 Personal And Advertising Injury $1,000,000 Any One Person or Organization Each Occurrence $1,000,000 Damage to Premises Rented To You $1,000,000 Any One Premises Medical Expense $5,000 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. Limit Of Insurance Bodily Injury to Participants $1,000,000 Each Occurrence Professional Liability $1,000,000 Each Wrongful Act Limit Abuse, Molestation, or Exploitation Defense Cost $100,000 Per Claim / $100,000aggregate Reimbursement per policy period Endorsements Forms and endorsements applying to this Member Certificate and made part of the policy at time of issue: Refer to master policy including all state amendatory endorsements applicable to the state of this Member Certificate 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: $179.00 To review the Master Policy: Please send a written request to the Plan Administrator shown above. Countersigned: 03/28/2024 By: '�°� Date AUTHORIZED REPRESENTATIVE MCGL 1002 07 21 Page 2 of 3 5tdWarm State Farm Mutua. Automob:'e Insurance Company 44277-1-A MUTL VOL PO Box2358 DECLARATIONS PAGE Bloomington IL 61702-2358 NAMED NSURED AT3 75-1354-1 A A ' POLICY NUMBER 805 5304-801-75 °ffia SANIA & VICTORIA POLICY PER'OD FEB 012024 to AUG 012024 12 01 A.M. Standard Tme EL SEGUNDO CA 90245-2962 STATE FARM PAYMENT PLAN NUMBER 1073121923 AGENT ED BARNHART 502 MA.N ST EL SEGUNDO. CA 90245-3069 PHONE (310)322-8911 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE T AN AMOUNT ;S DUE. THEN A SEPARATE STATEMENT fS ENCLOSED, YOUR CAR YEAR MAKE. MODEL BODYSTYLE VEKCLE ID, NUMBER CLASS 2023 TOYOTA TACOMA P•CKUP SYMBOLS - COVERAGE & LtWTS PREMIUMS A Lab"ty Coverage $190 4 Body Injury L'm`ts Each Person, EachAcodent $2507000 $500:000 Property Damage L'm't Each Aoc'dent $100*0 C Med`ca' Payments Coverage $12 94 L'mt - Each Person $,000 D Comprehens've Coverage - $256 Deduct'b a $68, 38 G Co5s'on Coverage -$250 Deductb'e $258-33 H Emergency Road Serv'ce Coverage $2, 58 R1 Car Renta� and Trave Expenses Coverage $35 = 96 L'm4 - Car Renta Expense Each Day- Each Loss $50 $1,200 U Un'nsured Motor Veh'ce Coverage $22-57 Bodl,y Injury Urnis Each Person. Each Aco dent $30,000 $60:000 U1 Un nsure . Motor Veh c'e PE2yerty Damage Coverage $1,79 Total premIum for FEB 012024 to AUG 01I 2024, 592, 98 This is not a taGNt. ;MPORTANT MESSAGES 'IMPORTANT NOT`CE For your protecton. Ca` torn"a `aw reeu'res the fo ow'ng to appear w'th th"s po 'cy= Any person who know-ng:y.presents fa se or fraudju'ent 'intomlat on to obta'n or aamend `nsurance covera a or to make a c Win for the payment off a oss s gu"ty of.a came and may be subject to t nes and cant nement "n staple pr"son, Rep'aced po' cy number 3128537-75E. New Po cy Form EXCEPT'aONS, POLICY BOOKLET & ENDORSEMENTSp(See poi'cy bpooklet & 'nd'v�dual endorsements for coverage details.) UR POLICY CONSISTS H AWL S U NY EO THIS rENNO - S TIAPPLYAG N L 8I�C8L SMSS D�TO YOU 6 D M S,S4T RY RAGEENDOFOR REIPTRSDKVAL VEHICLE SHARING. Agent ED BARNHART Te-ephone (310)322-6911 01 730511033 _� See Reverse S de Prepared FEB 05 2024 1354-A75 +SXM xa: This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first Insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non -assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington„ Illinois, on the second, Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secret.vy President IMPORTANT NOTICE: California lawrequires us io provide you with Information for tiling complaints with the Slate Insurance Department regarding thecoverage and service provided under this policy. Your agent's name and contact information are provided on the front of this document. Another option is to reach out by mail or phone directly to.: State FarrrO Executive Customer Service PO Box 2320 Bloomington, IL.61"702 Phone # 1-800-STATEFARM (1-800-782-8332) Department of Insurance complaints should be tiled only after you and State Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Phone # 1-800-927-HELP (4357) or visit i aura ce ca. ov101-ccra umer NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company ma �rr cancel a policy before the end of the currentpptolicy period for reasons described in the provision trt6ed Cancellation which i located in the General forms section of your policy (refer to the Contents in the beginning of your policy for the page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured under the policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. I. Convictions for violatingg troy provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made byan insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons thatare not listed above but which are lawful and not unfairly discriminatory. -Jo e.o 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING Phis endorsement is a part of the polio I-Neepl for the chaangce this endorsement makes. all other provisions of the policy remain the same and apply to (his endorsement. 1. LIABILITY COVERAGE a. Exclusions EXChlsl(an 15. is replaced by the following: THERE IS NO COVERAGE TOR AN LNTSURIU) FOR THE OWN- ERSIRR MAW'1 NANCI. OR USIi OF I Y)UR CAR OR A.NIFVL]' ACQUIRED CAR WHILE USED IN 11,76O.-YAL I G111CLI S11.4RI\'G. This exclusion does not apply to you and resident rela- tives whoa. and only if. the Illl amount of all available limits of all other liability bonds. policics. and self-insurance plaits that apply have been used up by payment ot'judg- nlents or sellfcnlenis. or have been ollcred in writing. b, jr Other Liability Coverage Applies 'I'lic first paragraph of item 2. is changed to read: The Liability Coverage. provided by this policy applies as primary cov- erage for the ownership. mainte- nance. or use of your car or it trailer attached to it, except while your car or a trailer attached to it is used in personal vehicle sharing. The Liahilily Coverage provided by this policy applies as excess cover- age for the ownership. mainte- nallec, or Ilse of your car or a trailer attached to it while tour car or a trailer attached to it Is used in personal vehicle sharing. 2. MEDICAL PAYMENTS COVERAGE . Exclusions (1) Exclusion 3. is replaced by the fol- lowing: 'rni--RE IS NO COVERAGE FOR AN IA:SURID WHO IS OCCII,PYI G A VEHICLE WhIILI IT IS REN-rL) OR L ASED TO OTHERS BY AN I:VSURI:'D. This exclusion does not apply to you and rwd- dent relat;vex while accupring your car or a nenly acquired car while used in personal vehicle sharing; when_ and only it. file lull amount of all availa- ble limits of all other sources of medical payments coverage or similar vehicle insurance that apply have been paid. (2) Exclusion 13. is replaced by the fullms.ing: '171IERE IS NO COVERAGE FOR AN I.NSURI:'D WI{O I.S OCCIi1'1'L7%!G YOUR CAR OR A :SL9,'1,Y ACQUlliliD CAR WHILE USED IN I'l_IiSOA-- AL 1-7.7111CLE SHARING This exclusion does not apply to you and resident relatives when. and only if the fill amount of all available limits of all other sources of medical payments coverage or similar vellicic insurimcc that apply have been path. Pa c I of3 6126MD Copyrighl. Stale Farm \-luum Automobile Insurance Company, 2013 b. If Other Medical Payments Coverage or SimiiarVehicle Insurance Applies The gird paragraph of item 3. is changed to read: The Medical Payments Coverage provided by this policy applies as primary coverage for an insured who sustains bodily injtery while occupying your car or a trailer attached to il. except while your car or a trailer attached to it is used in personal vehicle .sharing. The Magical Patvllte is Coverage provided by this policy applies as execs coverage I'm you and resident rela- tives who sustain Ilvdih' in#ury while occupying your car or a mailer attached to It while your car or a trailer attached to it is used in personal vehicle sharing. 3. UNINSURED MOTOR VEHICLE COVERAGE a. Exclusions Exclusion 6. is replaced by the IblloNving: T1117,RE IS NO COVERAGE, FOR AN LNSURPD WHO IS OCCU- PITNG YOUR CAR OR A ;VEIV- L), ;ICQU1Rl:'l) all? WhllLri USED IN 1'lildSO\i-II 11WIC1J: S11,-11{LVf:. This exclusion does not apply to you and resident rela- tives when. and only if the full amount of all availablc limits of all other sourcaS of uninsured motor vehicle coverage that apply have been paid. b. If Other Uninsured Motor Vehicle Coverage Applies The firs) paragraph of item 2. is changed to read: 'the Uninsured Motor Vehicle Cov- craga provided by this polio- ,alp Plies aS primary coverage for are. Insured evllo susiains be' r ittjor ° ■xilile vc€upt'ing yolrr cur. except while your car is cleat in personal vehicle sitraring. nic L nhwurcd Motor Vehicle Coverage provided by this policy app lic+ as excess' eoverauc Iorvoll and M-411e111 rela- tives e%ho sustain badity injury while Occupying ,rnur car while Pour car is used in personal vehi- cle.sh ar;ng. 4. PHYSICAL DAMAGE COVERAGES a. Exclusions (1) exclusion 2. is replaced by file lol- loeving: '111111(J IS NO COVERAGE FOR ANY C0I171U I) 17111- CL WHILE 11' IS W-WIT'D OR IJ ASfiD'1'U O'1'IlJsi25 Hy AN L 'SURIs'D. 'Phis exclusion d Plot peOewotatltlaly tit yearn Par or;) rrly acy€trired car feltlle used rrem al va hit lr slurring fal-wri. and only ii: llic full aaalla U111 Of .ell available 111114ls. of all other sources of physical damage coverage or samik-tr coverage fhc( apply have been paid. (2) Exclusion 20, is replaced by the followiaig: TH1R.I� IS NO COVERAGE FOR IOUl2 CAR OR A NE 11•= I_1 :IC )U11W1) C•IR WI IIL I usfiD IN P1:160N4L 11,111 CLE .S11AR1AW. This cxclu- siou does not apply when, and Only il: the full amount of oil available limits of all other sources of physical damage Page 2 of 3 b 126MD �`_ C'npyrighl. Suite Farm \9ulual _latvnlohilc lasurance Company. 2013 r» z Z A. coverage or similar co%wilac primary coverage for a loss to potir that ripply have been paid. car. except while your car is used If Other Ph sisal Oama !e Coverage in personal vehicle sharing. The or Similar do or physical damage coverages pwwid- The first t paragraph of itent 3, is ed by this policy apply as c\eess changed to read, coverage ror a lass to your car The ph.sr -il datuage coverages while it is used in perrortal Vehicle provided by this policy apph- as sharing. fags 3 of 3 G 126MD 93, Copyright, Star. Farm iv4uuial Automobile lnsuranee Company_ 2013 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. U I have and will maintain workers' compensafion 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 # t L/) 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 with those provisions or the agreement will automatically become void - Signature of Applicant Date Print Name 1 C—U,ZiA -15dE&VIA Agreementfor. S119/7) i n Dated: Z-- / 2-- �') (;L Reviewed by: `1 `I