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PROOF OF INSURANCE (2025 - 2025)SOUTBAY-48 CR-, CERTIFICATE OF LIABILITY INSURANCE DATE 9124/2024 i 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. _ µ IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED pro _ visions 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(!). PRODUCER World Insurance Associates, LLC 64 Portsmouth Ave Exeter, NH 03833 772-4781 INSURER Vantapro Specialty. Insurance Company ..... 144768 INSURED INSURER., B„ { INSURER ......... .. ff _ South Ba S routs LLC C Y P ` 1603 Aviation Blvd f INSURER D Redondo Beach, CA 90278 , INSURER E __ INSURER F : .................. ..._,. ..... ....... ......_ COVERAGES GES CERTIFICATE NUMBER ........, _ _ REVISI.O.N,,,��U�MBER: 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. A X COMMERCIAL ...OF I ADDL SUB....._._ ... 1 .. R� ... - . 11A,1kLIC EXP �C�-..I LIMITS JJjR_ GENERAL LIABILITY p P --- .� . ... y TYPE OF INS �RAN� E � _. POLICY UMBER POLICY EFF POLICY EACH OCCURRENCE 1 X0,000 .. L.. IMAGE TO RENTED -- � � 300 Q00,. ktl tiFslrr �arael 5 000 CLAIMS X occuR 5077-2734-00 7/3/2024 7/3/2025 ffMEDEX,PIPPyonelersonJ .. ..... ..... 1,004,000 IV. AG, "J4 ,PERSONAL. S. ADV INJURY .,..� $ ._. , .. Cfi, 000 X REE APPLIES CpMP/OP - . N �q'.aA�t LIMIT A-GENERAL1. $ 3,000 �❑ S PER. O LOC PRODUCTS .. RE4"T .... AGG $ OO�II F�LICY PRO- ..,-,. ..... .. 1 O0 ,,. _i OTJHE"R .. $ AUTOMOBILE LIABILITY CCUMBINED'S6NCIl„E LIMIT ANY AUTO BODILY INJURY (Per oersoni $ , OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY,INJURY,(Peracciden[) _ HIRED NON -OWNED (� P�Pd".VPER7"YDAMAGE .....� AUTOS ONLY ................� AUTOS ONLY ,lP,er rec.tldepr.. .......®....... OCCUR EXCESS LIAB CLAIMS-MADE,mAGGREOATERRENCE �........,$. --- -- r � .......... ..,...,. I UMBRELLA LIAR .......,, ............. DED RETENTION $ WORKERS COMPENSATION PER 1. OTH AND EMPLOYERS' LIABILITY — ~>TAT�: ANY PROPRIETOR/PARTNER/EXECUTIVE ECUTIVE NIA A CCIDENT ____ FEtlI LRrM -MBER EXCLUDED. E L SEAS Mandatory n NH) LOYE . If yes, describe under OESCRIPTION OF OPERATIONS below I „ _W „ _„„„„„„„ DISEASE- LIMIT $ A Accident -Student or US2151924-00 7/3/2024 7/3/2025 100,0011 DESCRIPTIO04 OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Addlldonal Remarks Schedule maybe attached It more space is required) (2024-2025) Gymnastics: Any Person or Organization including certificate holder Is additional insured'' if written signed contact to such exists prior to loss subject to form indicated above in General Liability Section. (2024-2025) The City of El Segundo, its officers, officials, employees, agents, and volunteers is additional insured if written signed contact to such exists prior to loss subject to form indicated above in General Liability Section. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Cityof El Segundo its officers, officials, employees, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9ACCORDANCE WITH THE POLICY PROVISIONS. agents and volunteers 350 Main St _. --- ._._.--- El Segundo, CA 90425 AUTHORIZED REPRESENTATIVE ......... .................... ...... .....,... . .......... ...... ............ ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL -INSURED - Y'' BITTEN CONTRACT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization with whom you have agreed to add as an additional insured by written contract but only with respect to liability arising out of your operations or premises owned by or rented to you. GL 00008 00 (04/09) GEICO GENERAL INSURANCE COMPANY Washington DC MAILING ADDRESS PAIGE HANNAH NEGRETE VERIFICATION OF COVERAGE (SEE BELOW UNDER CAUTIONARY NOTE) Policy Number: 4604090011 Effective Date: 10-16-24 Expiration Date: 04-16=25 Registered State: CALIFORNIA To whom it may concern: This letter is to verify that we have issued coverage under the above policy number for the dates indicated in the effective and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle meets or exceeds the financial responsibility requirement for your state. This verification of coverage does not amend, extend or alter the coverage afforded by this policy. Vehicle Year: 2016 Make: MAZDA Model: 6 VIN: COVERAGES Bodily Injury Liability Each Person/Each Occurrence State Minimum $15,000/$30,000 Property Damage Liability State Minimum $5,000 Uninsured & Underinsured Motorists Each Person/Each Occurrence Comprehensive (Excluding Collision) Collision X Lienholder LIMITS DEDUCTIBLES $15,000/$30,000 $5, 000 $15,000/$30,000 Additional Insured Interested Party JP MORGAN CHASE BANK PO BOX 90......._ .. 1. 033..,-,. _ FORT WORTH TX„76101-2033.111. _ .__. Additional Information: Issue Date: 10-15-24 If you have any additional questions, please call 1-800-841-3000. $500 Ded $500 Ded/Waiver CAUTIONARY NOTE: THE CURRENT COVERAGES, LIMITS, AND DEDUCTIBLES MAY DIFFER FROM THE COVERAGES, LIMITS AND DEDUCTIBLES IN EFFECT AT OTHER TIMES DURING THE POLICY PERIOD. THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES, LIMITS, AND DEDUCTIBLES AS OF THE ISSUED DATE OF THIS DOCUMENT WHICH IS SHOWN UNDER "ADDITIONAL INFORMATION" OR IF AN ISSUED DATE IS NOT SHOWN, THE DATE OF THIS FACSIMILE OR EMAIL. U33 12-17 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. 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 (_J 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # (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 to provisionr the agreement will automatically become void. N Signature of Print Name Agreement for: I Dated: 10 )?� ' Reviewed by: Date 30 ! ZaZ�(