PROOF OF INSURANCE (2026)J
insurance
COMMERCIAL GENERAL LIABILITY COVERAGE FORM - IQ
SPECIFIED PROFESSIONAL LIABILITY COVERAGE FORM -
THIS POLICY IS WRITTEN ON A CLAIMS MADE
Issue Date: Olt OPTS
(4,
110
"IMS MADE COVERAd
IT IS AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HO tR LISTED BELOW TO CERTIFY
COVERAGE UNDER THE COMMERCIAL GENERAL LIABILITY IN!SURAN eA"-! 'PE " ASTER POLICY LISTED BELOW.
7—
CERTIFICATE HOLDER: 1vorme Do [a Torre, Ivorme Do La 31"'
—
POLICY NUMBER:
S0220GL00000200
ADDRESS: 15821 Firmona Avenue, Lar tpe C h 10260
CERTIFICATE NUMBER:
BB15666922
CERTIFICATE POLICY PERI 03/01112025 O 03101120
7;04 AM MST AT YOUR ADDRESS S14604'ABOV
INSURANCE COMPANY: Accelerant SpecialtyVlur"nce Company
SRDE
NAMED INSURED: BEAUTY HEALTH TALLIAI"
ADDRESS: 333 West Wacker Drive Sulte 300, OyIL60606
MASTER POLICY PERIOD: 03101/2025 TO 03101/2026
12;01 A.K STANDARD TIME AT YOUR ADDRESS SHOWN
LIMITS OF INSURANCE
General and Professional Aggregate Limit (Other than Products -
Completed Operations) $3,000,000
'Personal and Advertising Injury Limit INCLUDED
General and
Damage to Premises Rented to You Limit i300,0010 Any One Premises
"m6cTiZW M-00tWEIrnit, 41
RETROACTIVE DATE: 03101/2023
THIS INSURANCE DOES NOT APPLY TO "BODILY INJURY-, -PROPERTY DAMAGE- OR "PERSONAL AND ADVERTISING
INJURY' WHICH OCCURS BEFORE THE RETROACTIVE DATE, IF ANY, SHOWN ABOVE,
BUSINESS TYPE
rf] individual Tedinidan
Comod Tmt.,MOom i-v. Do W Tw.
DESCRIPTION: 13 Massage Therapist 0 Esthetician 0 Cosmetologist 0 Hair Stylist 0 Barber El Nail Tech 0
Reiki / Energy Worker 0 Lash Artist 0 Body I Face / Henna Painter 0 Aromatherapy 0 Animal Massage 0
Reflexology 0 Fitness Trainer 0 Acupuncture Z Other (Face painter)
Entity type- 0 Corporation 0 Partnership or Joint Venture 0 LLC 0 Individual/Sole Proprietor Other:
FORMS AND ENDORSEMENTS
THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM(S) AND ANY
ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. THESE DECLARATIONS, TOGETHER WITH THE
COMMON POLICY CONDITIONS AND COVERAGE FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE
NUMBERED POLICY
EN —Ls alfaclred to thLs policy: REFER TO S GL 220 00 16 05 24
BB10002
Page 1 of 2
I le
)J,
ADDITIONAL COVERAGE OPTIONS — Coverage Applies When Checked
❑ Cupping Endorsement
❑ Micro -Current Endorsement
❑ Acupuncture Endorsement
❑ Dietary and Nutritionist Endorsement
❑ Ad -hoc Endorsement
❑ Fitness Endorsement
❑ Primary, Noncontributory
❑ Specific Waiver of Subrogation
❑ Loss Payee
❑ Primary, Noncontributory $ Waiver of Subrogation
❑ CG 20 37 Additional Insured — Owners, Lessees Or Contractors — Completed Operations
❑ CG 20 11 Additional Insured — Managers or Lessors of Premises
❑ Earlier Notice of Cancellation Provided by Us BBI
❑ 1 Year - Extended Reporting Period (SL taxed)
❑ 2 year - Extended Reporting Period (SL taxed)
❑ 3 Year - Extended Reporting Period (SL taxed)
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
UPON REQUEST. PLEASE READ THE POLICY AND ALL ENDORSEMENTS
CLAIMSIINCIDENTS REPORTING
Full detail of any incident should be sent immediately by email to Claims@ideal3.com, Phone: (844) 443-3253, Fax: (612) 230-9875,
or submit via your customer dashboard
NO ADMISSION OF LIABILITY MAY BE MADE EITHER VERBALLY OR IN WRITTING
IN RETURN FOR PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL OF THE PREMIUM $55.00
TERMS OF THE POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE SURPLUS LINES TAX $1.65
AS STATED IN THIS POLICY. STAMPING FEE $0.10
TOTAL COST $56.75
Administrated By:
Veradtylnsurance
Solutions, LLC
260 South 2500 West
Suite 303
Pleasant Grove Utah
"062
80.520.6993
��;:�: p�irb, Pf.'eC•'..l�,f.u'4.'
�Y all . �cfror Pls uao'
Administrator's Signature:
'q y pa/ is l�6
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
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 pr vision'S or the agreement will automatically become void.
Signature of Applicant Date
Print Name
Agreement for: ►- (.
Dated: G
Reviewed by: