PROOF OF INSURANCE (2026)ACC>RV DATE (MMIDDIYYYY)
�11 CERTIFICATE OF LIABILITY INSURANCE 07/29/2025
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 have ADDITIONAL INSURED provisions or 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 CONTACT
Maguire Insurance Agency, Inc. FWI NAME:
1 Bala Piz Ste 100 PHONE FAX
Bala Cynwyd, PA 19004-1401 (A/C, No, Ext):
610.617..7900 E-MAIL
ADDRESS:
INSURERS) AFFORDING COVERAGE NAIC #
INSURER A: Philadelphia Indemnity Insurance Company 18058
INSURED INSURER B
The Kelly School of Irish Dance
INSURER C:
1217 E,Oak Ave
El Segundo, CA 90245 INSURER D :
INSURER E
INSURER F 1.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER t
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
I TYPE OF INSURANCE
ADDL
INSD
I SUBR
WVD
j
POLICY NUMBER
POLICY EFF
(MM/DDIYYYY)
POLICY EXP
(MMIDD/YYYY.)
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
PHPK605261-015
08/28/2029
08/2812026
EACH OCCURRENCE
$2,000,000
DAMAGES( RENTED
CLAIMS -MADE 11 OCCUR
PREMISES {Ea occurrence)
$100,000
PROFESSIONAL LIABILITY
'.. X
MED EXP (Any one person)
$2,500
PERSONAL & ADV INJURY
$2,000.000
GEN'L
GENERAL AGGREGATE
$3,000.000
AGGREGATE APPLIES PER:
X
"LIMIT
AT"�
POLICY pl I PROJECT � LOC
.PRODUCTS -COMP/OP AGG
$3,000,000
L�
SAM AGGREGATE
$300,000
OTHER
SAM OCCURENCE 1
$100.000
COMBINED SINGLE LIMIT'
AUTOMOBILE LIABILITY
(Ea accident)
$
BODILY INJURY (Per person)
$
ANY AUTO
OWNED AUTOS
ONLY SCHEDULED AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
HIRED AUTOS 'NON -OWNED
ONLY AUTOS ONLY
(Per accident)
$
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
�'
'... $
AGGREGATE
$
-
EXCESS LIAB CLAIMS -MADE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER
STATUTE
OTHER
E.L. EACH ACCIDENT
$
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
NIA
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
I E.L. DISEASE -POLICY LIMIT
S
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
''... It is understood and agreed that the following entity is added as an additional insured but only with respect(s) to the operations of the named insured except that liability resulting from the additional insured's sole
''. negligence.
CERTIFICATE HOLDER
St. Lawrence Martyr Catholic Church
1900 S Prospect Ave
Redondo Beach, CA 90277
CANCELLATION
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
4-
@ 1988-20ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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. PHPK605261-015
( X) 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: 8/26
Carrier Philadelphia Indemnity Insurance Co Policy Number Expiration Date
Name of Agent Team of Agents Phone # 877-438-7459
( 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
Signature A ply with those provision pr h a reeement will automatically become void.
g pp Well Date 11/25/2025
Print Name Claire Maxwell
Agreement for:
Dated:
Reviewed by: