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PROOF OF INSURANCE (2024 - 2025)AC40RE CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/14/2023 CERTIFICAT E 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 ADFATIONAL INSURED, the policy(ids) 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 riahts to the certificate holder in lieu of such endorsement(s). PRODUCER K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 MM — Entertainer & Performer 1800-328-2317 FAX entertainers@kandkinsurance.com 1-260-459-5502 INSURER(S) AFFORDING COVERAGE NAIC # ........� INSURED INSURER A: Markel Insurance Company 38970 Hlrotaka Sunny Sekl INSURER B: DBA: Sunny Sekl INSURER C: 610 E Marshall Street ••• San Gabriel, CA 91776 INSURER D: INSURER E: A Member of the Sports, Leisure & Entertainment RPG INSURER F- rnvconr_cc r`FRTIFIr'ATF NIIMRFR• Wngswi17Fi 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. L' TR TYPE OF INSURANCE INSD WVD POLICY NUMBER L MM/DD P UCY MM/DD/YYYY LIMITS -- A X COMMERCIAL GENERAL LIABILITY X MlRPGOOOOOOO161900 01/01/2024 01/01/2025 EACH OCCURRENCE $1.000,000 CLAIMS- 12:01 AM EDT 12:01 AM t5 oAMAei N _ $1,000,000 MADE OCCUR PREMISES .Ea Occurrence W MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP/OPAGG $1,000,000 POLICY PRO- LOC JECT PROFESSIONAL LIABILITY OTHER: LY PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE I Ea accident BODILY INJURY (Per person) ANY AUTO OWNED AUTOS SCHEDULED a BODILY INJURY (Per accident) - ONLY AUTOS HIRED NON -OWNED PRO"''E AMA AUTOS ONLY AUTOS ONLY (Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND NIA PER OTHER STATUTE EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N E.L. EACH ACCIDENT EXECUTIVE OFFICER/MEMBER E.L. DISEASE —EA EMPLOYEE EXCLUDED? (Mandatory in NH) (� If yes, describe under DESCRIPTION E.L. DISEASE— POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS ''.. MlRPGOOOOOOO161900 01/01/2024 01/01/2025 PRIMARY MEDICAL $5,000 12:01 AM EDT 12:01 AM EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Performing as Puppeteer, Story teller 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. CERTIFICATE HOLDER UANf1 r_LLAIIUIN The City of El Segundo, its officers, officials, employees, agents, and SHOULD ANY OF THE A96VE DESCRIBED POLICIES BE CANCELED BEFORE volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (Owner/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 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: M1RPG000000O161900 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 Name Of Additional Insured Persons Or Organization(s) The City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 Named Insured: Hirotaka Sunny Seki DBA: Sunny Seki Information required to complete 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 i INSURANCE - Commerce West Insurance Company Your Producer: 1207 TATSUNO BUSINESS SERVICE, INC. 923 E. THIRD ST. #104 LOS ANGELES CA 90013 213-626-9341 Named Insured: JUDITH SEKI 610 E MARSHALL ST SAN GABRIEL, CA 917764222 Customer Since: 02112/1999 Notes for Policy or, if applicable, Endorsement Reason PERSONAL AUTO POLICYDECLARATIONS CA GROUP AUTO (CA) These are your Declarations. Please Read and Attach to Your Policy. Insurance Provided By: COMMERCE WEST INSURANCE COMPANY, PO BOX 8006, PLEASANTON, CA 94588 POLICY INFORMATION mmm PoItcy Number Declaration Type RENEWAL Policy Period From: 08/12/2023 To: 02/12/2024 6401050003536 Transaction Effective Date: 08/12/2023 12:01 A.M. Standard Time at me address of the Named insured, t�+af rpot prior to the time applied for or, if this is;") replacement declarations, net prior to the time coverage change was eegue5ted. 12:01 A.M. Standard Time at the address of the ..-..... . . . ..... NEW OR VEHICLE INFORMATION EXPIRING RENEWAL V H ZIP GARAGE91776 VEH USE ANNUAL MILEAGE ANNUAL RATED MII EAGE D IV ERID # YEAR MAKE AND MODEL VIN - 1 TOYOTA SIENNACELE DRIVE TO WORK/ SCHOO L 3852 3852 4 2015 HONDA CIVICHYBRID 91776 PLEASURE 14356 14356 0408 TY COVE GES AND LIMITS OF LIABILITY Coverage is provided only where a premium and a limit of liability are shown for the coverage. LimitsofLiability refx�auas � .. Coverage � omd,actdml�_. _ ch.F4rc Vehicle 1 Vehicle 4 ._. , ...._�.. BODILY INJURY $100 000 � $300 000 $129.00 , $193.00 PROPERTY DAMAGE.._____ �- ................-- �.— N/A $100 000 $88.00 $135.00 ..., m MEDICAL PAYMENTS $2,000 N/A $8.00 $12.00 UM BODILY INJURY - � $25 00$50 000 $29.00 $40.00 �.. g g e 1 Vehicle a forlJama e to YourAufo Vehicle le 4 UM PROPERTY DAMAGE COMPREHENSIVE $500 $500 $3.00 $13.00 COLLISION $500 $500 $77.00 ! $309.00 UM COLL DEDUCTIBLE WAIVER $500 $500 $2.00 $3.00 RENTAL REIMBURSEMENT S20/$600 $20/$600 $11.00 $11.00 TOWING & LABOR SPECIAL EQUIPMENT Total Premium Per Vehicle $347.00 $716.00 Total Fees _ $1.76 (Included Amount) AN'N FRAUD FEE_ $1.76 TOTAL AMOUNT $1,064.76 (For all VePaic)es on the Policy, Including Surcharges) Page 1 of 2 70001 (0 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 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 Name of Agent Policy Number Expiration Date Phone # mplI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not oy 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 ly c I cant ', thos, proVis-1-06 or the agreement will automatically become void, 9 Pp i z.1 z 1 2:4 _ immediate) comply with � � Date --�-�---s- Print Name - r Agreement for: Dated: Reviewed by: