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PROOF OF INSURANCE (2024 - 2025)CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 03/01 /2024 T IS CER'TtF LATE IS ISSUED T9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOR T " ATE OLO R. T S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 1 PORTAN : If t e certificate o er is an AD IT O L INS" D„ the po Ic,y(le must have ADD TtONAL INSURED provisions or Be, endorsed I 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 ri hts to the certificate holder in lieu of such etldorsement , PRODUCER CONTACT NAME- MM - Dance Instructors K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne, IN 46804 1-800-506-4856FAX1-260-459-5502 mac' No, Ex1 `' Arc Ne ADDRESS: info@fitnessinsurance-Acorn oU t CUSTOMER 10: INSURERS) AFFORDING COVERAGE NAIC # INSURED INSURER A: Markel Insurance Company 38970 Thomas Hickey DBA: Tommusic DJ Services INSURER B: INSURER c: Los Angeles, CA 90034 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: U00060965 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. INS LTR TYPE OF INSURANCE _ INS-t, 1M1ND POLICY NUMBER POLICYTFF —(MMIDD Y EXP 1 IMMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X MIRPGOOOOOOO131500 03/07/2024 O3/O7/2025 EACH OCCURRENCE $1,000,000 CLAIMS X OCCUR MADE 12:01 AM EDT 12:01 AM T PREfau1SES ta Occurrence)$1,000,000 MED EXP (Anyone person) $5,000 PERSONAL &ADV INJURY $1,000,000 _ GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1,000,000 PRO- POLICY ❑ JEC?.. ❑ LOC RPARTICIPANTS PROFESSIONAL LIABILITY $1,000,000 OTHER' $1,000,000 AUTOMOBILE LIABILITY OWNED 9101-9LI I IEa accident ANY AUTO BODILY INJURY (Per person) . ONLY OWNED AUTOSE AUTODULED() BODILY INJURY PeraccidenlHIRED NON -OWNED ONLYAUTOS ONLY M_AAUTOS Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLALIA13 OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A STATUTE E OTHER ANY PROPRIETORIPARTNER1 YIN E.L. EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Li E.L. DISEASE- EA EMPLOYEE It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached it more space Is required) Non Certified Instructor of: Country Western 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. f,t:Ri WiCA t E HOLDER CANCELLATION The City of El Segundo, its officers, officials, employees, agents, and SHOULD ANY OF THE AigOVE D I3 POEIZIE9 BE CA CEL ED BEFOR volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 339 Sheldon St ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Owner/Manager/Lessor of Premises ° 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 (2016103) 9)1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MlRPG000000O131500 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 Name Of Additional Insured Persons Or Or anization s The City of El Segundo, its officers, officials, employees, agents, and volunteers 339 Sheldon St El Segundo, CA 90245 Named Insured: Thomas Hickey DBA: Tommusic DJ Services Information required to com fete this Schedule, if not shown above, will be shown in the Declarations. 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 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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 �M1 interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy, If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAMED INSURED (item 11 HICKEY, TOM LOS ANGELES CA iWow AUTO POLICY NUMBER: CAA 083765818 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 12-03-23 12:01 A.M. POLICY EXPIRATION DATE: 12.03.24 12:01 A.M. VEHICLES VEH. IDENTIFICATION YEAR MAKE MODEL VEHICLE GARAGE ANNUAL"" VERIFIED SALVAGE NO. NUMBER USE ZIP CODE MILES MfLEAGE 1 1995 BULK CENTURY SW PLEASURE 90034 501 - 1,500 VERIFIED NO 3 2002 DODG DAKOTA CREW CAB PLEASURE 90034 2,501 - 3,500 VERIFIED NO 4 1989 BULK CENTURY SW CUSTOM PLEASURE 90034 1,501 - 2,500 VERIFIED NO 5 1986 BULK SKYHAWK CUSTOM PLEASURE 90034 501 - 1,500 VERIFIED NO 6 1983 DODG 600 PLEASURE 90034 501 - 1,500 VERIFIED NO COVERAGES AND LIMITS ANNUAL PREMIUMS Coverage is not In effect unless a premium or the word "included" Is shown. COVERAGES LIMITS OF LIABILITY Vehicle 1 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 I Liability " » Bodily Injury $100,000 each person/ $300,000 each occurrence $ 157 ; $ 326 ; $ 174 $ 142 $138 Property Damage $100,000 each occurrence $ 100 $ 220 $ 108 $ 90 $ 87 Medical I ; No Coverage: No Coverage a No Coverarge: No Coverage; No Coverat Physical Damage (Actual Cash Value unless olhenaise slated, less deductible) Vehicle 1 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 0 + N Comprehensive ACV ACV ACV ACV ACV $ 99 $ 91 w $ 66 $ 48 e $ 48 (Less Deductible) $250 $250 $250 $250 $250 Collision ACV ACV ACV ACV ACV v $ 67 $ 195 $ 53 w $ 35 $ 32 (Less Deductible) $500 $500 $500 $500 $500 Car Rental Expense (Per Day) No Cover a a No Coverage _ No Coverage No Coverage No Cover , a! No Coverage ° No Covera e t No Coverage,, No coverage,,No Coverag. Uninsured Motorist ` Bodily Injury - $50,000 each person/ $100,000 each accident $ 62 $ 66 $ 66 $58 $ 56 » » Uninsured & Underinsured Vehicles : „ l Uninsured Deductible Waiver Included Included Included Included Included Uninsured Collision N No Coverage , No Coverage: No Coverage; No Coverage: No Coverai Total Premium ; $ 485 ; $ 899 ; $ 487 $ 373 $ 361 PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage" page contained In your renewal package. "No Coverage" indicates coverage not purchased. Total Annual Premium' $ 260: (Includes all applicable discounts.) Less Policyholder Savings Dividend $ 11, Net Premium* $ 2491 CAM200A PROCESS DATE 10-30-23 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) U ffi 3Dl 1p3'12 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. L) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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 # I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not mploy 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 thas provisions or the agreement will automatically become void. 3 Signature of Applicant Au' Date Print Name x Agreement for: Dated: Reviewed by: