PROOF OF INSURANCE (2025 - 2026) CLOSEDCERTIFICATE OF LIABILITY INSURANCE
09/18/2024
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 AME40, EKTEND OR ALTER TIME COVERAGE AFFORDED BY THE POLICIES BELOW,
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER„ AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED„ the ppolicy IDS) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of tie ; cy, certain policies may require an encrersemot. A statement on
this certificate does not confer rfghts to the certificate holder In lieu of such endorsernent(s).
PRODUCER I CON'rACTNAME: Mass Merchand°Isino
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne IN 46804
1-800-3282317 1 N,a;, 1-260-459-5502
info@eventinsurance-kk.com
INSURED 2001491819 CP# 524 INSURER A: Markel Insurance CoPt1W:� 1p� ...., 38970
Natalie Strong INSURER B: .� .�.
INSURER C:
INSURER D:
emLBISUre &Enteainment RPG HIPPO,INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2000642395 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.
INSR ADDL SUBR POLICY F POVC 1':XP
LTR TYPE OF INSURANCE INS'D WVD POLICY NUMBER MMi'OOPYY MMiDDIYY LIMITS
A X COMMERCIAL GENERAL LIABILITY X X M➢RPGOOOO000352400 09r17a4 OlI117125 EACH OCCURRENCE $1,000,000
12:01 AM 12:01 AM DAMAIsE TO RNq"EtI $1,000,000
C'LAlr;9"A0E F OCCUR PREMIISES Ea Oa um a{vcm
MED EXP (An,y one gaaasan) $5,000
PERSONAL & ADV INJURY $1,000,000
FG-EN'LGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000
ICY [D PROJECT �LOCPRODUCTS-COMP/OPAGG $1,000,000
ER: PROFESSIONAL LIABILITY $1,000,000
LEGAL LIAR TO PAPmCIPANTS $1,000,000
AUTOMOBILE LIABILITY M' AN .... 111 L LI L - I a
aCCl. aril
ANY AUTO BODILY INJURY Wor peaeaonl
OWNED SCHEDULED _._.
AUTOS ONLY AUTOS BODILY INJURY IPer =WUPI p
HIRED NON -OWNED iiYZ1AY4;
AUTOS ONLY HAUTOS ONLY daga danr
0MSPIELLA OCCUR
IJAB EACH OCCURRENCE
EXCESS LIAR CLAIMS -MADE AGGREGATE
DED RETENTION
WORKERS COMPENSATION N/A PER STATIITE GDTN'4ER
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/ Y / N E,.R..„ EACH ACCIDENT
EXECUTIVEOFFICER/MEMBER CC "EN
EXCLUDED? (Mandatory In NH) Q E L. (DISEASE - EA EMPLOYEE
IIy s, de ribe undo
DESCRIPnON OF OPERArI0N3 bel'a�aa E.L.'DISEASE - POLICY LIMIT
MEDICAL PAYMENTS FOR PA 'TICIPANTS
PRIMARY MEDICAL
EXCESS MEDICAL
BWCRWP79167Y OF OPER+p6TIONS 9 LOCATIONS I VQ4ICLES IAMBRD R5T, Addgibanaai ' maiks $4htdulo, may be alla'd 04 II mare space is requlrarl)
Instructor of: Artistic painting, Clay work and/or pottery, Craft making, Drawing, Sculpting
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.
Primary and Noncontributory is added via form MGL 1574
Waiver of Transfer of Rights of Recovery Against Others to Us is added via form CG2404
CERTIFICATE HOLDER CANCELLATION
City of Ef regundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
350 Main St EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
El Segundo, CA 90245 1 THE POLICY PROVISIONS.
Owner/Manager/Lessor of Premises
AUTHORIZED REPRESENTATIVE
0 1988-2015 ACORD CORPORATION, All rights reserved.
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.
ACORD ' 25 (20110103) The ACORD name and' logo are registered marks of ACORD
POLICY NUMBER: M1 RPG0000000352400
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 following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Persons Or Organization(s)
City of El Segundo
350 Main St
El Segundo, CA 90245
Named Insured: Natalie Strong
CP# 524
I 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:
1. 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.
CG 20 26 0413 0 Insurance Services Office, Inc., 2012 Page 2 of 2
POLICY NUMBER: M1 RPG0000000352400
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 following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Nam�OfAddltlonal Insur11 ed Persons Or Or aniation sCity undo
350 Main St
EI Segundo, CA 90245
Named Insured: Natalie Strong
CP# 524
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:
1. 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.
CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2
DON HARRISON
4825 TORRANCE BLVD STE 10
TORRANCE, CA 90503-4172 FARMERS
IIII45URAINCIE
Auto Insurance Coverage Change
Your Farmers PoUcy
Policy Number: 15744-84-75
Effective: 12/20/2024 12:01 AM
NATALIE STRONG
Expiration: 8/5/2025 12:01 AM
EL SEG U N DO CA 90245-3808
Your Farmers Agent
Don Harrison
4825 Torrance Blvd Ste 10
12/23/2024
Torrance, CA 90503-4172
(310) 371-9100
Dear Natalie Strong,
dharrison@farmersagent.com
Thank you for giving us the opportunity to serve your auto insurance needs. This packet
To file a claim log on to Formers.com
reflects recent changes made to your policy.
or the Farmers@ Mobile App or call
1-800-435-7764
A summary of your premium and policy change information is shown below.
Premium at -a -glance
. .... . b p 4
.... . .. . . .... . # µ M y
D ' you know?
p
Full -term Premium (excluding fees) $2,597.00
Manage Your Policy Online
Prorated Premium
Log on to farmers.com to pay your
Prior Period (12/20/2024- 2/5/2025) $30.40
bill, get insurance ID cards, view
Next Period (2/5/2025 - 8/5/2025) $128.00
................._....,,, _ _.............,m..._ _
policy documents, and more! Plus,
access your account anytime using
Totalfaiirtlils"III"ui,ansactiouii $158.40
the Farmers Mobile App! Text
GETAPP to 29141 to download it
This is not a bill.
Your bill with the amount due will be mailed separately.
today!
Go Paperless
Summary of Changes
Save stamps, time and trees .... Go
Paperless! You can choose to
Previous Current
receive your Farmers policy
2018 Mazda Cx-5 4D V:128
documents and/or billing statement
electronically. Enroll at farmers.com
Vehicle Use Commute Business
and choose the paperless options!
If you have any questions or would like to learn more about our other insurance products
and services, please contact your agent.
We appreciate your business.
Sincerely,
Farmers Insurance Group@
25-8164 1-14
-- - s Markel Insurance Company
MARIff
Personal and Business Owner's Umbrella Declarations
Named Insured: Broker:
KraftNatalie Strong 29 7zake Insurance, Inc. -
9
4825 Torrance Blvd.
Ste 10
El Segundo CA 90245-3808 Torrance CA 90503
Contact: Don Harrison
Phone:310-371-9100
Policy No: MPU0256438-00 Policy Period: 1/24/2025 To 1/24/2026
(12:01 AM standard time at the address of the Insured.)
Coverage A: Bodily Injury, Personal Injury, Advertising Injury and Property Damage Liability Coverage
Limits of Liability for Each Loss: $1,000,000
* Policy Total Limit: Not applicable
* The Policy Total Limit shown in this policy's Declarations for Coverage A is the most we will pay for all losses arising out of business
operations and/or business property during each policy period.
Coverage B: Excess Uninsured and Underinsured Motorists Bodily Injury Coverage
Limits of Liability for Each Loss: $0
Policy Total Limit: $0
Self Insured Retention: None ($0)
Charges Policy Premium: $371
Total Policy Premium: $371
MUP 0001 (03/21)
Attached to and forming a part of Form: MJIL 1000 (06/10)
MDUP 1000 (05/19)
Endorsements Attached to this Policy at Time of Issue: MIDLU12140(09/17)9)
MUP 1302 (10/20)
MPIL 1073-CA (05/14)
MPUP 1004-CA (05/19)
State and Privacy Notices: MPUP 1005-CA (05/19)
MPIL 1007 (01/20)
MPIL 1083 (04/15)
Administered By, Authorized Representatives:
Personal Umbrella.com Insurance Services, Inc. John K. Clark
P. O. Box 8586
Emeryville, CA 94662 I�
(800)564-1799
MDUP 1000 (05/19) Umbrella Declaration Order ID:L279145 INVID:2258053 Doc#:1 Issue Date:issuedate Producer Print Date: 1/26/2025
(Page 1 of 1)
Umbrella Schedule
Policy No: MPU0256438-00 Effective Date: 1/24/2025
Expiration Date: 1/24/2026
Covered Persons: Natalie Strong
Personal Umbrella
Personal Property
Following are the locations declared in your application covered under a Personal Liability or Homeowners policy
Personal Residences, Primary Insurance Company &
Rentals or Vacant Land Limits of Liability (in thousands)
El Segundo CA- Personal Residence Farmers $300
Personal Drivers
Following are the drivers declared in your application and are the only drivers who live in your household and/or regularly drive your vehicles.
Drivers Date of Birth Drivers License #
Natalie Strong
Personal Automobiles
Following are personal vehicles listed in this policy and covered under a personal auto policy.
Personal Automobiles Primary Insurance Company &
Limit of Liability (in thousands)
2018 MAZDA CX-5 4D 2WD TOURING Farmers $250/500/100
2011 NISSAN LEAF ELECTRIC 5D Farmers $250/500/100
Personal Uninsured/Underinsured Motorist
Following are policies covering uninsured motorist listed in this policy and covered under a personal auto policy.
Primary Insurance Company & Limit of Liability (in thousands)
NOT COVERED
Unlicensed Vehicles, JetSkis & Watercraft
Following are unlicensed vehicles, jet skis and watercraft listed in this policy and covered under a liability policy.
Description Primary Insurance Company &
Limit of Liability (in thousands)
NOT COVERED
Losses arising out of a property, auto, unlicensed vehicle or watercraft that is acquired or leased during the policy period are
covered by this policy if they are covered by your primary insurance listed above or another replacement insurance company
A.M. Best rated B+ (VII) or higher.
MDUP 1001 (05/19) Umbrella Schedule Order ID: L279145 INVID: 2258053 Issue Date: 1/24/2025 Producer Print Date: 1/26/2025
Umbrella Schedule
Policy No: MPU0256438-00
Covered Persons: Natalie Strong
Effective Date: 1/24/2025
Expiration Date: 1/24/2026
Business Owner's Umbrella
WARNING: THIS POLICY DOES NOT COVER ANY BUSINESS PROPERTY OR OPERATIONS.
Business Operations
Following are operations listed in this policy and covered under a business liability policy.
Description Primary Insurance Company &
Limits of Liability (in thousands)
NOT COVERED
Business Automobiles
Following are business vehicles listed in this policy and covered under a business auto policy.
Business Automobiles Primary Insurance Company &
Limit of Liability (in thousands)
NOT COVERED
Business Non -Owned Automobiles
Following are policies covering non owned Auto listed in this policy and covered under a business auto policy.
Primary Insurance Company & Limit of Liability (in thousands)
NOT COVERED
Business Uninsured/Underinsured Motorist
Following are policies covering uninsured motorist listed in this policy and covered under a business auto policy.
Primary Insurance Company & Limit of Liability (in thousands)
NOT COVERED
Coverage for Business Owner's activities are limited to those described in this section only.
We do not provide coverage for any other business operations.
MDUP 1001 (05/19) Umbrella Schedule Order ID:L279145 INVID:2258053 Doc#:1 Issue Date:1/24/2025
Please review your policy and discuss with your broker the coverage you do not
understand or wish to change.
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
■y y+� yy br y� �,a e.
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 Coale § 3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No.
U I have and will maintain worke(s' 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 Policy Number Expiration Date
Name of Agent
Phone #
CV1 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 t eco a sub"ect to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply wit o r s or the agreement will automatically become void.
Signature of Applicant Date
Print Name
Agreement for.
Dated:
Reviewed by: