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PROOF OF INSURANCE (2024 - 2025) CLOSEDCERTIFICATE 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: