PROOF OF INSURANCE (2025 - 2025) CLOSEDr— DATE (MMIDD/YYYY)
..- CERTIFICATE OF LIABILITY INSURANCE 03/2212024
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 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 CONTACT
NAMAcrisure, LLC PH11ON.
370 OLD COUNTRY RD STE 200 CI"II p Ex1): 516) 746 4141 A , No
GARDEN CITY, NY 11530-1702 lemert@acrisure.com; mcorry@whitmoregroup.com;
ADDRESS: ygarcia@ grou
E-MAIL whitmore com;
p'
cbiviano whitmore rou .com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :
............... .�
INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND
INSURER t.:
ITS PARTICIPATING MEMBERS"
Grace Marie Maxwell dba Athletic Grace Dance Studio
INSURERC:
113 West Grand ave
INSURERD :
El Segundo, CA 90245
INSURERE:
INSURERF :
Great American Insurance Compan 1 16691
.+....�.,... ��. rvrrr�rnr•.ar•ew ^r ull Iue0o. A`AodOmar RFVICIr1W IJI.IMRFT ,
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.
THSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MWoD/YY MM/DD/YYYY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
S1,000,000
DAMAGE TO R
S300,000
X COMMERCIAL GENERAL LIABILI7Y
PREMISES
_ occurrence)
MED EXP (Any one person)
$10,000
CLA.-MADE fiCCUR
X HOSTLIOUORUABILITYINCLUDED
X
PAC 4725036
04/01/2024
04/01/2025
PERSONAL & Aov INJURY
sl,000,00a
A
12:00 AM
12:01 AM
X
_
INCLUDES ATHLETIC PARTICIPANTS _
GENERAL AGGREGATE
52,000,000
_.... .....
GEN'LAGGREGATE UMITAPPLIES PER:
PRODUCTS - COMP/OP AGG
S2,000,000
X POLICY Q LOC
COMBINED SINGLE UMI1`
AUTOMOBILE LIABILITY
(Ea accident)
_
BODILY INJURY (Per person)
ANY AUTO
BODILY INJURY (Per
ALLOWNED
MSC
AUTOS AUTOS
aceidenl.
NON-OWNED
PROPERTY DAMAGE
HIRED AUIO AUTOS
E
(I'yr accident
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
EXCESS LIAB CLAIMS -MADE
HP.IED
AGGREGATE
RETENTION S
04/01/2024
04/01/2025
EACH OCCURRENCE
S1,000,000
A
Professional Liability
X
PAC 4725036
12:00 AM
12:01 AM
AGGREGATE LIMIT
S1,000.000
04/01/2024
04/01/2025
EACH OCCURRENCE
S1o0.000
A
Abuse and Molestation
X
PAC 4725036
12:00 AM
12:01 AM
GENERAL AGGREGATE
5300,000
AD&D AGGREGATE
S500,000
04/01/
012:01
S100,000
A
Accident/Medical Coverage
BSR-F162220-00
12:00 AM
AM
AM
12:01 AM
MAXIAD&
MAXIMUM MEDICAL
$100,000
DEDUCTIBLE
$100
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Dance Studio - Ballet/Pointe, Ballroom, Tap, Jazz, Zumba (R), Cultural/Heritage Style Dancing, Modern. Locations: 113 West Grand ave - El Segundo, CA
90245
The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named insured during the policy period.
Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage
CFRTIFICOTF HOI nFR CANCELLATION
The City of El Segundo
300 Main st
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
Ac tri5.wre., LA-0
ACORD 25 (2016/03) U 1988-201ti AGUKU GUKt'UKAIIU". All ngms reserveu.
The ACORD name and logo are registered marks of ACORD
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 Grace Maxwell.
Date:
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:
L_) 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 #
V 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 with those provisions or the a reement will automatically become void.
Signature of Applicant Date
Print Name Grace Maxwell
Agreement for:
Dated:.
Reviewed by: