PROOF OF INSURANCE (2026):55 �l
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xCA S201i991 Came mnh OH 45202 4201
COMMERCIAL GENERAL LIABILITY COVERAGE FORM — CLAIMS MADE COVERAGE
SPECIFIED PROFESSIONAL LIABILITY COVERAGE FORM — CLAIMS MADE COVERAGE
THIS POLICY 19 WRITTEN ON A CLAIMS MADE COVERAGE FORM.
IT 15 AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE
UNDER THE COMMERCIAL GENERAL UABILI TY INSURANCE MASTER POLICY LISTED BELOW
INSURANCE COMPANY: GREAT AMERICAN RISK SOLUTIONS SURPLUS LINES INSURANCE COMPANY POLICY NUMBER:
NAMLD INSURED BEAUTY I IEALTf1 A TRADE ALIIANCE PLF 197552
CERTIFICATE HOLDER: Pamela Karten, DBA Smoky Hollow Music
ADDRESS: did East Grand Amrxle, EI Sagundu, CA 402d5 CERTIFICATE NUMBER:
POLICY PERIOD: 03611121202S TO 03102/202fi -LET766127
ENTITY I— t; e'mr0w,,nnP.eim 9 uaMr1oa Ihata nr Jont Venare f LLC Si. 9"iv,9i,kio ftwvoialaud
UI 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 M THIS POLICY
A. Speclfled Products, Goods, Operations and Premises Covered: All related premises and operations of the Insured, normal and Incideniatto the practice of
the covered prollessional services
B. Professional Services: Life Coaches Enar% Healing and Work, Tutors and Menlors,and their related professional services
C, Coverage Type: Individual Professional
LIMITS OF INSURANCE
General and Professional Aggregate Limit [Other than Produds-
Completed Operations[
Products- Complated Operations Aggregate Lmd
Personal and Advertising Injury Limit
Generai and Professional Each Occurrence Limit
Damage to Premises Rented to You Limit
Medical Expense Llmd
.
RETROACTIVE DATE:. .......................................... ..............................
RATE:
PREMIUM:
BHTA FEE:
SL Tax:
Stamping Fee:
TOTAL POLICY COST: [The cost is t00 h earnedlnon refundable)
�'2,000,000
$ 1,000.000
INCLUDED
S, 1,000.000
300,000 Any One Premsbs
5,000 Any Onb Pars,ii
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
DY=2023
FLAT
$119.00
$1 10.00
$3 57
$0 21
U32.78
NO ADIWpSSION OF LIABILITY MAY BE MADE EITHER VERBALLY OR IN WRMNO
FULL DETAIL OF ANY INCIDENT SHOULD BE SENT IMMEDIATELY BY EMAIL WLLAa W,44 PlNlt UM OR BY LETTER
TO VERACITY INSURANCE SOLUTIONS, LLC 260 SOUTH 26M WEST SUITE 303, PLEASANT GROVE, UT 64062,
AdmlMatratod by
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Va mcliV Imuraaas Saldatiaus, LLC
2d %Maass Fll x^ iil it N""l t la 3t'!a
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a" 626.BB93
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ADMINISTRATOWS SIONATURIE: µ
app.insurancecanopy.com
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:
L_) 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 0 Segundo, I will not
employ any person in any-nianner so as to become subject to the workers' compensation laws of California„ and
agree that, if I should beco me subject to the orkers' compensation provisions of Labor Code § 3700 1 must
Signature of ��Ino°ant �'""� �"�� ,,^� � automatically become void, � _
Y comply h t o � rrov�s�o or th' g eTont will aut Date �,� / zz,Z,, -
immediately com with
Print Name
Agreement for:
Dated'"
Reviewed by: