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PROOF OF INSURANCE (2025) CLOSEDAC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/11/2024 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 Tights to the certificate holder in lieu of such endorsement s). PRODUCER Next First Insurance Agency, Inc. PO Box 60787 Palo Alto, CA 94306 INSURED Novo Gym Repair Inc 113658 Hawthorne Blvd Ste 213 Hawthorne, CA 90250 ERACES CERTIFICATE NUMBER: 788416588 (855) 222-5919 A: State National Insurance Company, Inc. B, REVISION NUMBER:. AIC # 2831 ,.OI/ 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 IES BY PAID CLAIMS. -.... ........ ..........�_..._. .......... ...,--- LIMITS SHOWN MAY HAVE BEEN REDUCEDFF . j _........ RANGE ADGL sIuES POLICY LXP 9N*aRXCL....... 1 D dYYYY LIMITS LTR i WVD POLtC'YNUMBER.......... IT.MMdDO MP X COMMERCIAL MERCIAL GENERAL LIABILITY E $1 00 0 CLAIMS -MADE X OCCUR 0 Phku r ce) $1, 000.00 � 1 ED EXP A�aYaaroeersrrrR) M ( 000 00 $ -- A X igXT7YT70L3-02-GL 09/30/2024 09".30/2025 PERSONAL&ADVI1­11NJURY $1,00000000 — GEN'L AGGREGATE LIMIT APPLIES PER'1g0 AGGREGATE GENERAL AGGREGATE 000.:00 $1a.._ -.- , y PRO- X I I LOC P�OtIU & I S -COMP/OP AGG „O�M�U 001,3,00 ....... ... JECT .... .... ....- __ $... I$ OTHER E;RMB N �DRSINGLE LIMIT AUTOMOBILE LIABILITY ANY AUTO ,YeBODILY INJURY (Per person) $ .... --_ ....,1 OWNED 1. SCHEDULED 1. BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED IHOPFRTYOArbzAGE. $ AUTOS ONLY AUTOS ONLY ., . mQd?Ur_Irgidonl.P..... ....._. ............. ....... .... UMBRELLA LIAB OCCUR EACH OCCURHFNCE $ ,,,_ ... EXCESS LIAB taLA[M5 MADE '..... AGGREGATE �. _ ..... ............ DED RETENTION$ WOR14ERSCOMPENSATION 'PTAI'UT'Y' V rR1 ....._-~ AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOWPARTNEfWEXECU'fl'VE. '..... --- E L EACH ACCIDENT _ - 5 ........ . OFFICEMMEMSi^_R EXCLUOED'I ❑ (Mandatory In NiH) NIA''... EL. DISEASE EA EMPLOYEE ........ .. ..,... ......,. If ups, describe under O �SCRIPTIONOF OIPERATIONS Irelusw � E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is El Segundo Police Department. This Certificate Holder is an Additional Insured on the General Liability policy pper the Additional Insured Automatic Status Endorsement. All Certificate Holder privileges apply only if required by written agreement between the Certificate Holder and the insured, and are subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION El Segundo Police Department 348 Main St El Segundo, CA 90245 LIIrV��tEI CERTIFICATE LiI e7 r� t�d Click or scan to view 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 WARNING; FAILURE°l IS UNLAWFUL AND SUBJECTS AN EMPLOYERTO 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 # 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 provisi f"ts, r` the agreement will automatically become void. Signature of Applicant �� " " Dates Agreement for: Dated: