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PROOF OF INSURANCE (2026)A CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDnYYY> 10/13/2025 CERTIFICATE DOTHIS TE IS ISSUED AS A MA--ffF-R OF INFORMATOR ONLY AN5 S NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND O FER G TS U T E CE CATE HOLDER.THIS R ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU'RER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. I PORTANT: if the oertiticata holder is an ADDITIONAL INSURED, the policy(ies) must have ONTIONAL INSURED provisions or be endorsed. it 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 endorsements . PRODUCER CONTACT NAME.: MM — Entertainer & Performer K&K Insurance Group, Inc. pffwff_ Apo No Ext ; 1 n800-328-2317 Nc 1-260-459-5502 P.O. Box 2338 DrtEs�s: kinsurance comITmm entertallrers kand n Fort Wayne, IN 46801-2338 �- DD CUSTOMER in, _................. ...... INSURER(S) AFFORDING COVERAGE NAIC 9 ......... ....... ��.-......... .............-.... .......,—..-...... INSURED •__ ........... INSURER A: Markel I . . .�. Hirotaka Sunny Seki INSURER B: ..... . _.. ........... DBA: Sunny Seki INSURER C: 610 E Marshall Street - ---• San Gabriel, CA 91776 INSURER D A Member of the Sports, Leisure & Entertainment RPG INSURER E INSURER F: 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_�..-... LTR. TYPE OF INSURANCE I�NSD POLICY NUM POLMC _ POt.1C � M2�011AMY LIMITS ._ -EACH A COMMERCIAL GE .RPGOOOO000352•m••• M1 600 01/01/2025 01/01,)2'02'6 N EACNHIOCCURRE�cur $1,000 000 •X •••••• CLAIMS 101/ AM EDT A RE E _.. $1,000,000 OCCURILITY MADE PREMISES ef1e) SES _S MED EXP (Any one person) $5,000 — ...... .... ........, PERSONAL & ADV INJURY ... ,—........ ..m... . ......... ............ GENERAA ........... L AGGREGATE ......_ 000,0........... $S,000 OOO GEN'L . ........ AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP/OP AGG ... $1,000,000 POLICY ❑ PRO- ❑ LOC PROFESSIONAL LIABILITY It1ii�lF"I.• $1,000,000 OTHER: PARTIIOtPAN'rS' COMBINED MNGILE U I`:' AUTOMOBILE LIABILITY Fa acctdenl '.. ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED _ YINJURY(Peraccident) BODILAUTOS ONLY AUTOS HIRED NON -OWNED H �' •_•_•__ ._• '.. AUTOS ONLY ONLY Per accldenC _ ITITIT,„„,_, .. NOT PROVIDED WHILE IN HAWAII. UMBRELLA LIAB OCCUR EACH OCCURRENCE .........-..._�.......—... .. EXCESS LIAB CLAIMS -MADE AGGREGATE ............... ........ .... ....._....._-._.,.... DED RETENTION MNOr1KERS COMPENSATION AND N/A S OTHER I T TUTS EMPLOYERS' LIABILITY H ACCIDENT E L. EACH ,,,,,,,,, ANY PROPRIETOR/PARTNER/ YIN _ EXECUTIVE OFFICERIMEMBER E.L.DISEASE— EA EMPLOYEE . EXCLUDED? (Mandatory in NH) _ ....-.. _ ....._... ................. If'yes, describe under DESCRIPTION E.L. DISEASE— POLICY LIMIT OF OPERATION'S below.. A MEDICAL PAYMENTS FOR PARTICIPANTS M1RPG0000000352600 01101/2025 01/01/2026 PRIMARY MEDICAL $5,000 12:01 AM EDT 12:01 AM -' �_ EXCESS MEDICAL !. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Performing as Puppeteer, Story teller 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. The City of El Segundo, its officers, officials, employees, agents, and THE U EXPIRATION Ate,. OF TH'E AB E DESCRIBED POLICIES BE CANCELL BEFORE volunteers RATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) �r 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 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MlRPG0000000352600 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Or anlxation s The City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 Named Insured: Hirotaka Sunny Seki DBA: Sunny Seki Information re uired to com late 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 © Insurance Services Office, Inc., 2012 Page 1 of 1 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: (U 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 ploy 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,pl9visionyor the agrrment will au ically become void. Signature of Applicant Print Name Agreement for: Dated: Reviewed by: Date ill �