PROOF OF INSURANCE (2025 - 2025) CLOSEDGPE43 IERICA.'Y
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Great MeerlrBn RlYk Sotutlaars Surplus tJnes Insurances Campanq
bL7...9YC.J. av a a+1{1kbM'.5.' cp, 301 E Fourth Sltuul., 2:3 S
IY94k:iiJ.16993 Cincinnati, OH 45202 4201
COMMERCIAL GENERAL LIABILITY COVERAGE FORM - CLAIMS MADE COVERAGE
SPECIFIED PROFESSIONAL LIABILITY COVERAGE FORM - CLAIMS MADE COVERAGE
THIS POLICY IS WRITTEN ON A CLAIMS MADE COVERAGE FORM.
IT IS AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE
UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW.
INSURANCE COMPANY: GREAT AMERICAN RISK SOLUTIONS SURPLUS LINES INSURANCE COMPANY
POLICY NUMBER:
NAMED INSURED: BEAUTY HEALTH 8 TRADE ALLIANCE
PLF055676
CERTIFICATE HOLDER: Pamela Karten, DBA Smoky Hollow Music
ADDRESS: Avenue, FJ Segundo, CA 90245
CERTIFICATE NUMBER:
POLICY PERIOD: 0310212024TO03/0212025i nAMMOTATYouaADDRESSSHMM
-LET141482
ENTITY: r Corporation I° Partnership or Joint Venture r LLC Sole Propristorllndividual
IN RETURN FOR PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL OF THE TERMS OF THE POLICY, WE AGREE WITH YOU TO PROVIDE
THE INSURANCE AS STATED IN THIS POUC'Y,
A. Specified Products, Goods, Operations and Premises Covered: All related premises and operations of the Insured, normal and incidentalto the practice of
the covered professional services
B. Professional Services: Life Coaches, Energy Healing and Work, Tutors and Mentors,and their related professional services
C. Coverage Type: Individual Professional
LIMITS OF INSURANCE
General and Professional Aggregate Limit (Other than Products -
Completed Operations) S 3,000,000
Products -Completed Operations Aggregate Limit S 1,000,000
Personal and Advertising Injury Limit S INCLUDED
General and Professional Each Occurrence Limit 5 1.000,000
Damage to Premises Rented to You Limit S 300,000 Any One Premises
Medical Expense Limit S 5,000 Any One Person
RETROACTIVE DATE:
03/02/2023
FLAT
RATE:
$119.00
PREMIUM:
8110.00
BHTA FEE:
$3.57
SL Tax:
50.21
Stamping Fee:
TOTAL POLICY COST: (The cost is 100% eamed/non refundable)
$232.78
THIS INSURANCE IS SUBJECT TO ALL THE TERMS AND CONDITIONS, INCLUDING APPLICABLE ENDORSEMENTS, OF THE
COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY. A COPY OF THE COMMERCIAL GENERAL LIABILITY
INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE. ADDITIONAL COPIES WILL BE PROVIDED TO THE
CERTIFICATE HOLDER IF REQUESTED BY THE CERTIFICATE HOLDER. PLEASE READ THE POLICY AND ALL
ENDORSEMENTS.
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 Pamela Karten.
Date;
■y:
Darrell George, City Manager
5:12
policyservicing.apps.progressive.com
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Policy Number. 97027330
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Customer Service
1-800.300.3699
24 hae f a �Ny, 7.1ays a -A
Verification of Insurance for
Pamela Karten
-his venh rat:en of insurance is not an in-rance r.clley and dar> no amend, extend
n aller the mwraye afforded by
the PC'I'Isled hiNotwdhstm6nc; any uayunam3ft, term of m^dLhon
cif arri contract or otPa davncil with
F—L b m,C, .his vef � wtcn rl Ir>;.uanoe may be —J or may aaWin, -,he w—drT a ello.ded Ey the pdices
described herein is sublea to as Ire terns, exdLsws and cuich Tons d ;he polaes
flease acc--Y- to s l ener as ver. h(dtlor o- insane la this pol: cy
Policy and driver information
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Vehicle information
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Coverage information
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9.1 InjOry uabihly i I5,000 ran oers iU,OOC
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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 Policy Number Expiration Date
Name of Agent Phone #
(1 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 shouldbeco ie subject to the orkers' compensation provisions of Labor Code § 3700 1 must
Signatureimmediately comply
with t oS r visio a or th a e ent will automatically become void.
P Y 7,s o ��� � Date
Print Name
�10—
Agreement for:
Dated; " 4
Reviewed by: