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PROOF OF INSURANCE (2026)AC "R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 11 1 11 /24/2025 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 certl 'icate hoider is an ADFATIFDNAL IOURE5, the policy(ies) must have ADDITIONAL SURED provisions or be endorsed, I 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 - Fitness Instructors . Hs N IT__..-. � -... _._ K&K Insurance Group, Inc. Aro No, Exr Info00fitn0essn s ran iAPD Np)"•••--1260-459-5502 P.O. Box 2338 tDY'ss. Fort Wayne, IN 46801-2338 ce-kk.com CUSTOMER ID: INSURER(S) AFFORDING COVERAGE ..........................__ .,,..,... _.. NAIC # �._.� ., __.._.._.- .. .... .... ................ INSURED ......_.....-..._..� INSURER A: Markel Insurance Company 38970 Madhavl Narayanan INSURER B: DBA: BollyPop LA INSURER C: _--- _. -- 3215 Overland Ave Apt 9171 - - — .... Los Angeles, CA 90034 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 000167183 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, lNSR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WVD MM/DD MMIDD/YYYY� LIMITS — A X COMMERCIAL GENERAL LIABILITY X M1 RPG000000050040 0 09/23/2025 09/23/2026 EACH OCCURRENCE $2,000,000 04:31 PM EDT 12:01 AM _ $1,000,000 MADECLAIM$, OCCUR PREMISES (Ea Occurrence ----- ......W .... MED ExP (Anyon0e per $5,000 --..._.._.. �............ ....._...-.-... PERSONAL & ADV INJURYmmmM- .--- $2,000,000 GENERAL AGGREGATE $5,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2,000,000 POLICY PRO. LOC � PROFESSIONAL LIABILITY $2,000,000 JEC'i OTHER: 1NJUY ...._..... ........ PARTICIPANTS $2,000,000 COMMINED S NGLE LIMI'..''. AUTOMOBILE LIABILITY E,� a,r,drrr�p ANY AUTO BODILY INJURY (Per person) OWNED AUTOS DY WWWWWX -• BODILY INJURY (Per accident) -..•_mONLY AUTOS HIRED NON -OWNED AUTOSONLY AUTOS ONLY ••••' Per accident L_....., NOT PROVIDED WHILE IN HAWAII UMBRELLALIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE' AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A P OTHER STATUTE EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ YIN '... E.L. EACH ACCIDENT EXECUTIVEOFFICER/MEMBER E.L. DISEASE- FA EMPLOYEE EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION EL. DISEASE- POLICY LIMIT OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL .......... ......_._._. DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Non Certified Instructor of: Cultural/Ethnic,Children's Fitness Programs, Exercise 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. CERTIFICATE HOLDER CANCELLATION City of El Segundo, its elected and appointed officials, employees, SHOULD ARY 6FE AI3'O'V-DESCRIBED POLICIE9 515 ZAPCELI ED BE FORE and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.. 350 Main St AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Owner/Manager/Lessor of Premises 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: MlRPG0000000500400 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 aniaation s City of El Segundo, its elected and appointed officials, employees, and volunteers 350 Main St El Segundo, CA 90245 Named Insured: Madhavi Narayanan DBA: BollyPop LA Information required to corn fete 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: 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 Name of Agent Policy Number Expiration Date Phone # (X) 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 provisions or the agreement will automatically become void. Signature of Applicant c Date 11 /21 /2025 Print Name Madhavi Nara anan Agreement for: Dated: Reviewed by: