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PROOF OF INSURANCE (2025 - 2025) CLOSEDAC 09/8/208/20CERTIFICATE OF LIABILITY INSURANCE DATE 1YYYY, 24 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 INSUREDS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT:: If the certificate holder is an ADDITIONAL INSURED„ the po icy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of tt'le 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 CONTACT NAME: Mass MerchandlSlnmmmmmmm . . - ....,.,................._......, ..,.�,.� ..........., K&K Insurance Group, Inc. ......_ PHONE fAlc. NP Exll 1-800-328-2317ITITIT �A/c Np m1m 260 459 5502 _. 1712 Magnavox Way E-MAIL info@eventinsurance-kk.com InfO�a%e,...,_._._.....,,...... Fort Wayne IN 46804 S ...... .ADDRESS: _ S, m....._ PRODUCER. CUSTOMER 10. - INSURER(S) AFFORDING COVERAGE IT NAIC It �����. �_ -----.. .............. 91819 CP# 524 INSURED 2001491819 urance Company 38970 INSURERA: Markel Ins -.. . Natalie Strong INSURER B: 212 Arena A Member of the Sports, Leisure & Entertainment RPG p ....... INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000642395 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. INSR LTR TYPE OF INSURANCE ADDL I SUBR POLICY NUMBER POLICY EFF POLICY EXP IM09/17/ LIMITS A X COMMERCIAL GENERAL LIABILITY XD XD M1 RPG0000000352400 M02 1 09/17/25 5 EACH OCCURRENCE $1,000,000 _._ V(,LAIJIfa`MAp'P�X OCCUR AM 12:01 AM DAMAGE TO RENTED Occurrence) _.... . IT ..I '.. MED EXP (Any one person) $5,000 PERSONAL&ADVINJURY _....._.... $1,000,000 ............... ._. -..-,.,......_......,........_..�.,,,�.� GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 '.. POLICY PROJECT 0 LOC PRODUCTS- COMPIOP AGG $1,000,000 OTHER: ....._ ITUABIurY PROFESSIONAL $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 MBIN IN L LI I ( a AUTOMOBILE LIABILITY iden ANY AUTO BODILY INJURY (Per person) OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE __ _ AUTOS ONLY AUTOS ONLY ........ ......... ...... UMB LLA OCCUR LL4Br..w EACH OCCURRENCE .......... -.._., . ............... EXCESS LIAB CLAIMS -MADE '.. AGGREGATE DED DRETENTION WORKERS COMPENSATION N/A PER STATUTE[___]OTHER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N E.L. EACH ACCIDENT ----._.�.....m.- EXECUTIVE OFFICERWEMBER WWE � EXCLUDED? (Mandatoryin NH � ) DISEASE EA EMPLOYEE E L ­� ,,, ,�_ _...„„„„„_ If yes desvibe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS MEDICAL MEDICAL [PRIMARY DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Ralnarks Schedule, may be aRaclred if more space is required) Instructor of: Artistic painting, Clay work and/or pottery, Craft making, Drawing, Sculpting 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. Primary and Noncontributory is added via form MGL 1574 Waiver of Transfer of Rights of Recovery Against Others to Us is added via form CG2404 CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 350 Main St EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH El Segundo, CA 90245 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE //,� ©1988-2015 ACORD CORPORATION, All rights reserved'. 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) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: M1 RPG0000000352400 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 City of El Segundo 350 Main St El Segundo, CA 90245 Named Insured: Natalie Strong C P# 524 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 0 Insurance Services Office, Inc., 2012 Page 2 of 2 INSURANCE WAIVER Pursuant to Section 4 of El Segundo City Council Resolution No. 4813, the undersigned authorized the waiver of commercial auto insurance for the City of El Segundo instructor contract with Natalie Strong. Date: 1 _2 ZS By Darrell George, City Mark r Cut here California " FARM E R S Evidence of Liability Insurance INS U RCAUWh:E. Policy Number: 157448475 Named Insured(s): Effective: 8/5/2024 Natalie Strong Expiration: 2/5/2025 NAIC Number: 2.1687 Underwriting Company: Mid -Century Insurance Company YourAgent: 6301 Owensmouth Ave, Don Harrison Woodland Hills, CA91367 Agent Phone: (310) 371-9100 Phone:1-888-327-6335 11 2nd Fold -.-. .,.- ----------- Vehicle(s): Registered Owner(s) fD 2011 Nissan LeafElectric5D 2018Mazda Cx-54D2WdTouring Patrick st Fold -.-. Contact Farmers Claim Department or Roadside Assistance 24 hours a day at (800)435-7764 Para Espanol, Ilame al (877) 732-5266 Report a claim at °www.ffarrners.corn, via the Farmers Mobile App or Contact your Farmers" Agent At the scene of an accident: 1. Obtain the following: —Name, address, and phone number of each driver, passenger, and witness. Obtain a driver's license number for each driver. — License plate number, insurance company, and policy number of each involved vehicle. — Photos of vehicle damage and accident scene. 2. Report the accident to the proper authorities. 3. Do not admit fault. An investigation may later reveal you were not responsible for the accident. n.eee .......... ........ ..... ... ... . c f0 This policy complies with Section 16056 of the California Vehicle Code m KEEP THIS CERTIFICATE IN YOUR VEHICLE AT ALL TIMES. 25-5973 1-19 IT __ Cuthere Instructions FOR STORAGE IN YOUR VEHICLE If you wish to keep this proof of insurance in your vehicle, cut along the indicated line or leave attached to the page as is and place inside your glove compartment. FOR STORAGE IN YOUR WALLET Step 1: Cut along the dotted line. Step 2: Fold along the line marked, "1st Fold" so that all information is facing out. Step 3: Fold along the line marked, "2nd Fold" so that the front of the card with the FARMERS logo is facing out. Step 4: The card should now fit conveniently into the credit card slot of your wallet. 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. C� 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 # ( ) 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 immediately comply wit ll o r s or the agreement will automatically become void. Signature of Applicant" Date Print Name Agreement for: Dated: Reviewed by: