Loading...
PROOF OF INSURANCE (2025 - 2025) CLOSED.4C - CERTIFICATE OF LIABILITY INSURANCE f DATE(MMIDDIYYYY) - ft_� 1 03/28/2024 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTENDD O t THE CERTIFICATE HOLDER. IS C TI I I OR ALTER THE COVERAGEE 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 poticy(ies) must have ADDITIONAL. INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, pertain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsernent s PRODUCER CONTACT NAME MM - Fitness Instructors tAA K&K Insurance Group, Inc. PHONE AIO No Ext : 1-800-506-4856 No). 1-260-459-5502 1712 Magnavox Way EwMMLinfo@fitnessinsurance-kk.com Fort Wayne, IN 46804 ADDRS,SS5 INSURERISI AFFORDING COVERAGE NAIC # INSURED Victoria K Samia El Segundo, CA 90245 A Member of the Sports, Leisure & Entertainment RPG INSURER A: Markel Insurance Company 38970 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 000065595 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. TR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMDR= JMMEDIYYYYLLIMITS A X COMMERCIAL GENERAL LIABILITY X Ml RP00000000131600 03/28/2024 03/2812025 EACH OCCURRENCE $1,000,000 CLAIM-"� 0Bfl2 PM EDT 12U1 AM $1,000,000 MADE I -- a,......00CUR PREMISES Ea OccurrenLe MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS —COMPIOP AGG $1,000,000 POLICY ❑PRO- ❑LOC PROFESSIONAL LIABILITY $1,000,000 'OTHER: PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY Ea accident)6LELIMI ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED BODILY INJURY (Per accident) � ONLY AUTOS HIRED NON -OWNED PDAMAGE AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA UAB OCCUR EACH OCCURRENCE '. EXCESS LIAB CLAIMS -MADE AGGREGATE DEJ RETENTION WORKERS COMPENSATION AND N/A 71 OTHER STATUTE EMPLOYERS' LIABILITY ANY PROPRIETOR(PARTNER/ YIN EL EACH ACCIDENT EXECUTIVE OFFICER/MEMBER ❑ EL DISEASE —EA EMPLOYEE EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION EL DISEASE —POLICY LIMIT OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) Certified Instructor of: Aerobics,Pilates 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 CANCELLATION City of El Segundo SHOULD AN OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE 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 POLICY NUMBER: M1RPG000000O131600 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULL` ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the loiiowinz COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or O anization s City of El Segundo 350 Main St El Segundo, CA 90245 Named Insured: Victoria K Sarnia 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: .. 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. 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 Victoria Samia Date, " S y Darrell George, City Mana r STATE FARMO This card is invalid if the policy for which it was issued lapses or is terminated. CALIFORNIA CAR INSURANCE CARD 5f`'-ramp POLICY NUMBER 650 9253-A09-75 INSURED SAMIA, & VICTORIA EFFECTIVE DATE SEP-29-2024 EXPIRATION DATE JAN-09-2025 CAR-YEAR/MAKENEHICLE IDENTIFICATION NUMBER 2024 MINI COOPER COUNTRYM S ALL COVERAGES A, C, D250, G250, H, R1, U. U1 The coverage provided by the policy meets the minimum liability limits prescribed by law. NAIC #25178 State Farm Mutual Automobile Insurance Company PO Box 853919 Richardson, Texas 75085-3919 AGENT BARNHART, EDWIN J 502 MAIN STREET EL SEGUNDO, CA 90245-3005 PHONE# 310-322-8911 STATE IFA,RW" .................................... IF YOU E AN MIE NIE NT- N0 1II1F POLICE IIIIII II IIEmmIIW "'1'11EL 1. Get names, addresses, and phone numbers of persons involved and witnesses. Also get driver license numbers of persons involved and license plate numbers/states of vehicles. 2. Promptly notify your agent, log on to statefarm.com', or use the State Farm mobile app to file a claim. 3. Don't admit fault or discuss the accident with anyone but State Farm or police. For EMERGENCY ROAD SERVICE use the State Farm mobile app, log on to statefarm.com, or call 877-627-5757, SEE POLICY FOR FULL NAME AND DEFINITION A Liability R1 Car Rental and Travel Expense C Medical Payments S Death, Dismemberment and D Comprehensive Loss of Sight G Collision U Uninsured Motor Vehicle H Emergency Road Service U1 Uninsured Motor Vehicle - PD L Physical Damage Z Loss of Earnings Submit this card or a photocopy of this with your vehicle registration renewal. One copy of this form should be carried in the vehicles at all times. The form may be needed as evidence of insurance in court.. Emergency Road Service information is located on your insurance card. 1001188 2004 144750 201 02-20-2018 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 forthe 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 # 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 �,.y�...� 4,�T,� y become void. immediately comply with those provisions or the agreement will utomaticill bec Signature of Applicant Date �7 Print Name Agreementfor-. Dated eF1'��� e. Reviewed bv: