PROOF OF INSURANCE (2026)" DATE (MMIDDIYYYY)
c"�R "' CERTIFICATE OF LIABILITY INSURANCE 10/17/2025
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 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 rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME;: Christopher HagStrom
NICKERSON INSURANCE SERVICES IA ICNq
(310)326-6333 Li N01 (310132s 5416
LIC #0491589 E-MAAL Christopher@nickersonins.com
ADDRESS:
2106 West Lomita Blvd. INSURERS AFFORDING COVERAGE NAIC #
Lomita CA 90717 INSURERA:Penn-Star Insurance Com an 10673
INSURED INSURER. B :
Cassidy Olson dba LA Pop Up Mini Golf INSURERC:
589 21st Street 'INSURER D:
Hermosa Beach CA 90254 1, INSURER F:
rn\iooer_cC CFRTIPIRATF NIIMRFR•25-26 GL 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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 XP LIMITS
TYPE OF INSURANCE POLICY NUMBER MMIDDPOLICYIYYYY MM/DDIY
LTRINqD
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A O R N ED
$ 100,000
A
CLAIMS -MADE OCCUR
a o
PREMISccurrence
E.
CPV0092319
6/4/2025
6/4/2026
MED EXP (Any one person)
_..
$ 5,000
...._
...............................................��....
PERSONAL B ADV INJURY
$ 1,000,000
WWW_
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY PRO LOC
PRODUCTS - COMP/OPAGG
$ Included
$
OTHER
OM
COMBINED 9.BNGOMIT
$E.
AUTOMOBILE LIABILITY
E ac0 entlw
BODILY INJURY (Per person)
' S
ANYAUTO
BODILY INJURY (Per accident)
'... $
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
-
....i'ROPERTY DAMAGE
Per accide.b
'..,. S
HIREDAUTOS AUTOS
UMBRELLA LIAB OCCUR
HCLAIMS-MADE
.EACi± OCCURRENCE
$
EXCESS LIAB
AGGREGATE
$
DEC) RETENTION $
$
WORKERS COMPENSATION
PER OTH-
STATLT ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L EACH ACCIDENT
$
.m.....
OF'FICERYMEMIBER E°XCL.0'DEW
NIA
(Marnfatcay In NH)
E,L DISEASE - EA EMPLOYEE
$
Iyes describ0. amber
�DESCRIPTION OF OPERATIONS below
I
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)
City of El Segundo is hereby included as an additional insured on the general liability with respects to
claims arising from the insureds covered operations *10 days notice of cancellation for non payment of
premium.
CFRTIFICATF HOLDFR UANULLLAI IUN
City of E1 Segundo
Department of Recreation
Parks and Library
401 Sheldon Street
El Segundo, CA 90245
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
n 1QRR_91111d ACORD CCIRPORATION. All rights reserved.
ACORD 25 (2014/01)
INS025 (201401)
The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS WHEN
REQUIRED IN A WRITTEN CONTRACT OR AGREEMENT
(OTHER THAN CONSTRUCTION)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
A. Section II — Who Is An Insured is amended to include as an additional insured any person or
organization when you and such person or organization have agreed in writing in a contract or
agreement that such person or organization be added as an additional insured on your policy. Such
person or organization is an additional insured only with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured or in connection with the
ownership, maintenance or use of that part of the premises leased to you.
However, the insurance afforded to such additional insured:
1. Only applies to the extent permitted by law; and
2. Will not be broader than that which you are required by the contract or agreement to provide for
such additional insured.
B. A person's or organization's status as an additional insured under this endorsement:
1. Commences during the policy period and only after such written contract or written agreement is
fully executed; and
2. Ends when:
a. Your ongoing operations for that person or organization described in Paragraph A. above are
completed;
b. You cease to be a tenant in that premises leased to you; or
c. This policy is cancelled or otherwise terminates;
whichever occurs first.
C. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply:
This insurance does not apply to:
1. "Bodily injury", "property damage" or "personal and advertising injury' arising out of the rendering
of or failure to render any professional architectural, engineering or surveying services, including
but not limited to:
a. Preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions,
reports, surveys, field orders, change orders or drawings or specifications;
b. Inspection, supervision, quality control, architectural or engineering activities; or
c. Engineering services, including related supervisory or inspection services.
GCG4000 04 23 Includes copyrighted material of Insurance Services Page 1 of 2
Office, Inc., with its permission.
This exclusion applies even if the claims against any insured allege negligence or other
wrongdoing in the supervision, hiring, employment, training or monitoring of others by that
insured, if the 'occurrence" which caused the "bodily injury" or "property damage", or the offense
which caused the "personal and advertising injury", involved the rendering of or the failure to
render any professional architectural, engineering or surveying services.
2. "Bodily injury" or "property damage" occurring after:
a. All work, including materials, parts or equipment furnished in connection with such work, on
the project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the location of the covered operations has been completed; or
b. That portion of "your work" out of which the injury or damage arises has been put to its intended
use by any person or organization.
D. With respect to the insurance afforded to these additional insureds, the following is added to Section
III — Limits Of Insurance:
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement you have entered into with the additional insured; or
2. Available under the applicable Limits of Insurance shown in the Declarations,
whichever is less.
This endorsement will not increase the applicable Limits of Insurance shown in the Declarations.
GCG4000 04 23 Includes copyrighted material of Insurance Services Page 2 of 2
Office, Inc., with its permission.
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.
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 Policy Number Expiration Date
Name of Agent 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 bect to the work compensation provisions of Labor Code § 3700 I must
immediately comply with se provisions e gent will automatically become void. 10/12/2025
Signature of Applicant
Print Name Cassi,
Agreement for:
Dated:
Reviewed by'.
Date