PROOF OF INSURANCE (2024 - 2024) CLOSEDI CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDOIYYYY)
03/19/2024
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, the policy(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
Verifly Insurance Services, LLC DBA Thimble Insurance Services
174 West 41h Street, Suite 204
New York, NY 10014
https://support.thi mble.com/
INSURED
Combine Academy
CA, 90056
djhowardO920@gmaii.com
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COVERAGES CERTIFICATE NUMBER: 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.
TYPE OF INSURANCE POLICY NUMBER _
INSR At1G $ia..__... POLICY EFF POLICY EXP LIMITS
LTR MMIDD/YYYY MMIDOIYYYY
X
COMMERCIAL GENERAL LIABILITY
08/05/2023
04/05/2024
EACH OCCURRENCE
S 1,000.000
❑X
CLAIMS -MADE OCCUR
2:00 PM
11:59 PM
P - I S Ea cccurrence
$ 100.D0g
PDT
PDT"
MED EXP {Any one person)
5,000
A
Y
Y
IBL-PKLLG2Y89
See note
PERSONAL & ADV INJURY
$ 1,000,000
-- - - -m-
On
_
GENL
AGGREGATE LIMIT APPLIES PER:
expiration
GENERAL AGGREGATE
$ 1,000.000
X
POLICY ❑ PRO-
JECT LOC
date below.
,PRODUCTS COMPIOPAGG
S 1,000,000
AUTOMOBILE
LIABILITY
CoMB�It�EDrINLLE LIMIT ... m
ANY AUTO
BODILY INJURY (Per person)
$
^^mmIT
OWNED SCHEDULED
AUTOS ONLYHAUTOS
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BODILY INJURY (Per accident)
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m
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-. �._..-.-..�...-.-._
ARCSF�ERTY' DAMAGE
S
m_
AUTOS ONLY AUTOS ONLY
m...
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
S ...
EXCESS LIAR n CLAIMS -MADE.
AGGREGATE
$
$
DED RETENTIONS
WORKERS COMPENSATION
OTH-
AND EMPLOYERS' LIABILITY YIN
R
TATUTE,_, �- E R
ANY PROPRIETORIPARTNERIEKECUTIVE
E L EACH ACCIDENT
$
EXCLUDED?
BE ? ❑
OFFICERJM(Mandatary
NIA
A
�
(Mandatory In H)
In
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E L. DIS64M
$
nder
describe
_.. _ ..- . w. ...�..�.._...
Dye
E OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
A
Professional Liability -Occurrence
Y
Y
IBL-PKLLG2Y89
2:00 PM PDT
1 L54 PM PDT'
EACH OCCURRENCE
$ 1.000 000
AGGREGATE
$ 1,000.000
$
''.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES fACORD 101, Additional Remarks Schedule, may be attached if more space Ismoluired)
*Please note that the insured has purchased a monthly policy that will automatically extend upon
expiration of the policy if the insured pays the appropriate premium. At that time, you will receive a new
Certificate of Liability Insurance, evidencing such extension.
con't on form Acord 101
Lr-K r Ir"IL.A I . r1'UILU K 'LrH.NUt_LLA I Iti..RN
The City of El Segundo, its
officers, Officials, employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
agents and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St.
El Segundo, CA 902455 AUTHORIZED REPRESENTATIVE
t
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: dihowardO920@gmail,Com
LOC #: 1
ADDITIONAL REMARKS SCHEDULE
AGENCY
Verifly Insurance Services, LLC DBA Thimble Insurance Services
POLICY NUMBER
IBL-PKLLG2Y89
NAMED INSURED
Combine Academy
CA, 90056
dihoward0920@gmail.com
CARRIER NAIC CODE
National Specialty Insurance Company 1 22608 1 EFFECTIVE DATE;
Page 1 of 1
ACORD 101 (2008101) @ 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Auto Insurance Confirmation
Please use this as confirmation of auto insurance. however. this doesn't take the place of an
insurance identification card.
Registered owner:
Address:
Policy number.
Policy effective date:
Policy expiration date:
Vehicle:
VIN:
Bodily injury liability limit:
Property damage liability limit:
Comprehensive deductible:
Collision deductible:
Lienholder.
DAVID J HOViARD
25829 SEAGRASS TRL
WILDOMAR CA 92595
CIC 020317064 7101
January 21. 2024
July 21 2024
2023 VOLKS TIGUAIN
I 1
550.000
each person 1
^ 100.000 each accident
510,000 each accident
5500
5500
USAA FEDERAL SAVINGS BANK
PO BOX 25145
LEHIGH VALLEY
PA 18002
Meets Califomia minimum statutory liability requirements
This confirmation of coverage neither affirmatively nor negatively amends. extends or alters the
coverage given by the policy issued by USAA. Casualty Insurance Company
Thank you for choosing us for your auto insurance needs If you have any questions_ please contact
us using one of the following options
Phone: 210-53i-USAA f8722i, our mobile shortcut #8722 or 800-531-8722
Fax: 500-531-887
Thank you
USAA Casualty Insurance Company
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.
(_) I have and will maintain workers' compensation 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 #
Lq 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
Signature of Applicant e
immediately comply with those provisions or t1� Pement will automatically become void.
3/13/24
Si
9 PP Date
Print Name David Howard
Agreement for.
Dated:
Reviewed by: