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PROOF OF INSURANCE (2025) CLOSEDDATE (MM/DD/YYYY) AC"R a CERTIFICATE OF LIABILITY INSURANCE 11 1'S/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(sl. PRODUCER Western Republic Insurance Services l NAAMEME:l � ,........ ...Dustin Keened PHONE 714 536 0500 19900 Beach Blvd F1 cA� .N�.Exta (71) - ADDREs$ dustln�ia Wrmsurance com Huntington Beach, CA 92648 -- - License #: OF23513 ................................IN.S,uR„E,R.IDAFFca,RglMcov INSURED INSURER B ; guar Tyr I�NSU�RER..��............................,.........................................................�.�.........,....................,...,,.......... Ja ennis Academ LLC 11650 Lakewood Blvd INSURER.. ,-... .. . Downey, CA90241 INSURERE; INSURER F : COVERAGES CERTIFICATE NUMBER: 00012866.241115092129 REVISION NUMBER: 1 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 _.....__ .... ,._.... ADDL SUBRy .... ......................................... POLICY EiFF POLICY EXP _LTR TYPE OF INSURANCE V POLICY NUMBER 'MMw"OOJYYYM " M. I LIMITS .... .... A ( "" COMMERCIAL GENERAL LIABILITY Y PHPK2583188 9/11/2024 9/11/2025 E �I-,U�O� OOO ._. ., CLAIMS -MADE OCCUR fi Ni ,AGHMIOCCURRENCEam, ' $. FI $1�_t OQO t... .. ................. ,.............. ........... ..... ,..... MAMAC ED EXP (Anyone pers _ . ..... ..... ... PERSONAL & ADV INJURY $ 1,000,000 PEN 4. AGGREGATE LIMIT APPLIES PER: G GREGATE I $ 3 PROD-T POLICY m.9EC.LOC ,000,000 P RODUCTS- COMP/OAGG $ 3P '000 000 OTHER, T $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I $ ANY AUTO BODILY INJURY (Per person) Is OWNED SCHEDULED AUTOS ONLY AUTOS ...,.,.. � -, BODILY INJURY (Per accident) $ '�C9PER)"M AdJaACE .._ $ ....... AUTOS ONLY AUTOS ONLY _I 19r 4.,'u�i 1RI) -- UMBRELLA LIAB I OCCUR EACH OCCURRENCE is EXCESS LIAR CLAIMS MADE, AGGREGATE ---- $ L.-RETENTION I ..... Is DED-... $ WORKERS COMPENSATION PER I L.... AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE �9TATI�T� � ER ,,,, ''.... OFFICER/MEMBER EXCLUDED? ElE,.L N 111 EACH ACCIDENT .,,.- ............ ......... i $ --------- -- --- (Mandatory in NH) EL DISEASE EA EMPLOYES $ If yes, describe under `----........................... ..... ........... ......... ......................... DESCRIPTION OF OPERATIONS below' E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. The certificate holder is named as additional insured per the attached PI-AS-009 (04/04). l_qi L•J lR1J a.l The City of El Segundo, its officers, officials, employees, agents and volunteers 401 Sheldon Avenue El Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by DCK on 11/15/2024 at 09:27AM Policy #PHPK2583188 PI-AS-009 (04/04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposures are provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy. Throughout this endorsement the words "you" and "your' refer to the Named Insured shown in the Declarations. The words "we," "us" and 'bur" refer to the Company providing this insurance. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. A. Supplementary Payments — Bail bonds increased to $2, 500/Loss of earnings increased to $500 each day; B. Tenant's Legal Liability — for Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers — Limit increased to $300, 000; C. Broadened Definition of Who Is An Insured, D. Amended Duties In the Event Of Occurrence, Claim Or Suit; E. Broadened definition of Advertising Injury — includes Televised Or Videotaped Publication; F. Amended definition of Bodily Injury to include Mental Anguish; G. Broadened definition of Personal Injury — includes Abuse Of Process/Discrimination; H. Amended Unintentional Failure To Disclose Hazards; L Amended Liberalization Clause J. Added Employee Indemnification Defense Coverage — We will pay up to $25, 000 in defense costs for an "employee" in a criminal proceeding (subject to established criteria); K. "Property Damage"- Removed exclusion for "Property damage" resulting from the use of reasonable force to protect persons or property, L. Added blanket Additional Insured — Funding Source; M. Added blanket Additional Insured — Managers or Lessors of Premises; N. Non -owned Watercraft— coverage length is increased to 58 ft. Page 1 of 5 PHILADELPHIA INDEMNITY INSURANCE COMPANY Includes copyright material of the Insurance Services Office, Inc., used with its permission. PI-AS-009 (04/04) A. Supplementary Payments In the Supplementary Payments — Coverages A. and B. provision: 1. The limit for the cost of bail bonds is changed from $250 to $2,500; and 2. The limit for loss of earnings is changed from $250 a day to $500 a day. B. Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protective systems" where it appears in: 1. The Limits of Insurance section of the Declarations as the Fire Damage Limit. That limit: a. Is changed subject to all the terms of Limit of Insurance (Section III) to the greater of: (1) $300,000; or (2) The amount shown in the Declarations as the Fire Damage Limit. b. Subject to a. above is the most we will pay to all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. 2. The last paragraph of Coverage A. (Section 1) after the Exclusions; 3. Paragraph 6. of Limits of Insurance (Section III); 4. Paragraph b.(1)(b) of the Other Insurance Condition (Section IV); and 5. Paragraph a. of the definition of "insured contract." C. Who Is An Insured Who Is An Insured (Section II) is changed as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage Part, paragraph 3.a. is changed to read: a. Coverage under this provision is afforded until the end of the policy period. D. Duties In The Event Of Occurrence, Claim Or Suit 1. The requirement in Condition 2.a. (Conditions, Section IV) that you must see to it that we are notified as soon as practicable of an 'occurrence" or an offense, applies only when the "occurrence" or offense is known to: (a) You, if you are an individual; (b) A partner, if you are a partnership; or (c) An executive officer or insurance manager, if you are a corporation. Page 2 of 5 PHILADELPHIA INDEMNITY INSURANCE COMPANY Includes copyright material of the Insurance Services Office, Inc., used with its permission. PI-AS-009 (04/04) 2. The requirement in Condition 2.b. that you must see to it that we receive notice of a claim or "suit" as soon as practicable will not be considered breached unless the breach occurs after such claim or "suit" is known to: (a) You, if you are an individual; (b) A partner, if you are a partnership; or (c) An executive officer or insurance manager, if you are a corporation. E. Advertising Injury —Televised Or Videotaped Publication The definition of "Personal and Advertising Injury" items 14. d., e., f. and g. is changed to read: "Personal and Advertising Injury' means injury arising out of one or more of the following offenses: d. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publication of material that violates a person's right of privacy; f. Misappropriation of advertising ideas or style of doing business; or g. Infringement of copyright, title or slogan. 2. 2. Exclusions b. and c. of Coverage B., Personal And Advertising Injury Liability, are changed to read: b. (2) Arising out of oral, written, televised or videotaped publication of material, if done by or at the direction of the insured with knowledge of its falsity; c. (3) Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period. F. Bodily Injury — Mental Anguish The definition of "bodily injury" is changed to read: "Bodily injury": a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (Item a. above) at any time. G. Personal Injury — Abuse Of Process/Discrimination If Personal and Advertising Injury Liability Coverage (Coverage B.) is not otherwise excluded from this Coverage Part: 1. The definition of "Personal and Advertising Injury" is changed by: Page 3 of 5 PHILADELPHIA INDEMNITY INSURANCE COMPANY Includes copyright material of the Insurance Services Office, Inc., used with its permission. PI-AS-009 (04/04) Revising Item b. of that definition to read: Malicious prosecution or abuse of process; b. Adding the following: "Personal Injury" also means discrimination based on race, color, religion, sex, age or national origin, except when: (1) Done intentionally by or at the direction of, or with the knowledge or consent of: (a) Any insured; or (b) Any executive officer, director, stockholder, partner or member of the insured; or (2) Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured; or (3) Directly or indirectly related to the sale, rental, lease or sub -lease or prospective sales, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured; or (4) Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. The insurance afforded by GA.b. above does not apply to fines or penalties imposed because of discrimination. H. Unintentional Failure To Disclose Hazards It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. I. Liberalization If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. Employee Indemnification Defense Coverage Under SUPPLEMENTARY PAYMENTS — COVERAGES A AND B the following is added: 3. We will pay on your behalf defense costs incurred by an "employee" in a criminal proceeding. However, you must have a prior written agreement with such "employee" whereby you agree to indemnify the "employee" for such defense costs and the agreement includes a provision for repayment of defense costs in the event of an adverse judgment. The most we will pay for any "employee" who is alleged to be directly involved in a criminal proceeding is $25,000 regardless of the number of employees, claims or "suits" brought or persons or organizations making claims or bringing "suits." Page 4 of 5 PHILADELPHIA INDEMNITY INSURANCE COMPANY Includes copyright material of the Insurance Services Office, Inc., used with its permission. PI-AS-009 (04/04) K. Extended "Property Damage" SECTION I — COVERAGES, COVERAGE A, 2. Exclusions a. is deleted and replaced by the following: a. Expected or Intended Injury "Bodily Injury" or "Property Damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. L. Additional Insured — Funding Source Under SECTION II — WHO IS AN INSURED the following is added: Any person or organization with respect to their liability arising out of: a. Their financial control of you; or b. Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. M. Additional Insured — Managers or Lessors of Premises Under SECTION II —WHO IS AN INSURED the following is added: Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions: This insurance does not apply to: a. Any "occurrence" which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. N. Non -owned Watercraft SECTION I — COVERAGES, 2. Exclusions, paragraph g. (2) is amended to read as follows: (2) A watercraft you do not own that is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. Page 5 of 5 PHILADELPHIA INDEMNITY INSURANCE COMPANY Includes copyright material of the Insurance Services Office, Inc., used with its permission. 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 Sergiu Boerica DBA Jaguar Tennis Academy. Date:: 2r By.• Darrell George, City Manager 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 Name of Agent Policy Number Expiration Date Phone # (X) 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 complywithwith those ovisio ns o; the agreement will automatically became void. Date 2/8/2024 Signature Print Name Agreement for: Dated:. Reviewed by: