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PROOF OF INSURANCE (2025) CLOSEDA`40R o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 03/28/2024 CERTIFICATE DOESNOT AFFIRMATIVELY OR NEGATIVELY — _.__ E 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. IMPORTART: 11 the certificate holder is an ADDM5RAL 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 riot confer rights to the certificate holder in lieu of such endorsements . CONTACT NA Me e MM -Fitness Instructors K&K Insurance Group, Inc. PHONE Ayc No AIc l Ext: 1-800-506-4856 No 1-260-459-5502 1712 Magnavox Way A PDREss: info fitnessinsuranoe-kk.com Fort Wayne, IN 46804 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Victoria K Samia 650 Mariposa Ave. El Segundo, CA 90245 A Member of the Sports, Leisure & Entertainment RPG .....�.....�., ror A. r.nueoro. wsURERA: Markel Insurance Company 38970 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: i rnnraccox; REVISION Nt1MRFR: 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. ILTR RSK A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS 1 MADE 1 X IOCCUR L..J. 'ADDLiNSD X WVD SUBRI POLICY NUMBER MlRPGOOOOOOO131600 MMID 03/28/2024 08.02 PM EDT MMIDD/YYYY 03128/2025 12A1 AM LIMITS EACH OCCURRENCE $1,000,000 PREMISES Ea Occurrence $1,OOD,000 MED IXP (Arty one person) $5,000 PERSONAL & ADV INJURY $1,000,000 '.GENERALAGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: , PRODUCTS —COMPIOP AGG $1,000,000 PROFESSIONAL LIABILITY $1,000,000 POLICY PRO ❑LOC JECT OTHER: (PARTICIPANTS R $1,000,000 AUTOMOBILE LIABILITY MBI D SING LIMI Ea accident BODILY INJURY (Per person) ANY AUTO OWNED AUTOS SCHEDULED ONLY AUTOS HIRED NON -OWNED NON -OWN AUTOS ONLY AUTOS ONLY Jr, , ` ( (� �pC r\ G J •^��Cff�� i `m W(f �, BODILY INJURY (Per accident) 'Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAR OCCUR EACH OCCURRENCE AGGREGATE ''. EXCESS LIAB CLAIMS -MADE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNER/ YIN NIA OTHER STATUTE EL EACH ACCIDENT EL DISEASE —EA EMPLOYEE EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL DISEASE —POLICY LIMIT If yes, describe under DESCRIPTION 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. L;IZK I n^P;A I t r"FUI..rU=K +:1:a1NK1r_ _ I norm Z:Ity of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. Dwner/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: MIRPG000000O131600 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY' ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the foiiowir.A COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of AdditionalInsured person s Or O anization,s City of El Segundo 350 Main St El Segundo, CA 90245 Named Insured: Victoria K Sarnia Information reouired to complete this Schedule„ if not shown above, will be shown in the A. Section II — Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s) or organization(s) additional insureds, the following is added to Section Ill shown in the Schedule, but only with respect to liability — Limits Of Insurance: for "bodily injury", "property damage" or "personal and If coverage provided to the additional insured is required advertising injury" caused, in whole or in part, by your by a contract or agreement, the most we will pay on acts or omissions or the acts or omissions of those behalf of the additional insured is the amount of acting on your behalf: insurance: 1. In the performance of your ongoing operations; or 1. Required by the contract or agreement; or 2. In connection with your premises owned by or 2- Available under the applicable Limits of Insurance rented to you. shown in the Declarations; However: whichever is less. 1. The insurance afforded to such additional insured This endorsement shall not increase the applicable only applies to the extent permitted by law; and Limits of Insurance shown in the Declarations. 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. ;ITY 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. C_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # ) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must y comply p r the agreement will automatically become void. ? 9Applicant�rs'..e immediate) corn with those Date 4 pr ovisions Signature of C Print Name �e°e � �$,"�� W�.�mP �.�, 9d° "" �7 ?_•.- Agreement for : ' m "11 6 ". Dated ,.. Reviewed by-