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PROOF OF INSURANCE (2026)COW CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ^^" " 03/03/2025 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. lMP RTANT: If the certificate holder is an ADDIT O A - IN URED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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 ri hts to the certificate holder in lieu of such endorsement s PRODUCER 'CONTACT NAME: MM -Dance Instructors K&K Insurance Group, InaNExp 1 800-506 4856 Nay; 1-260-459 5502 1712 Magnavox Way Fort Wayne, IN 46804 ORES& info@Iitnessmsurance-kk corn _...._.�""""""""""" INSURER(S) AFFORDING COVERAGE �.............. NAIC # IN............... ................._......._.. -.._. SURED a ....._.................. INSURERA: Markel Insurance Company 38970 Thomas Hickey INSURER B: DBA: Tommusic DJ Services INSURER C: 10540 National Blvd 12 _••••.....- ............... ,~°.... """""" •••••• . """"'� Los Angeles, CA 90034 INSURER D: _.....� A Member of the Sports, Leisure & Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 000110951 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. LTR. TYPE OF INSURANCE DL INSD SUBR W1/D POLICY NUMBER ...... POLICYEFF MMIDD POLICYEX'P MMIDD/YYYY. LIMITS _...",.,..._ A '... X COMMERCIAL GENERAL LIABILITY X M1 RPG0000000500200 03/07/2025 03/07/2026 EACH OCCURRENCE $1,000,000 CLAIMS 12:01 AM EDT 12:01 AM "— $1,000,000...... MADE X OCCUR III PREMISES Ea„"Occurrence .............. MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 _........... ....... GEN'LAGGREGATELIMITAPPLIESPER: ,�..........---__...-...,. PRODUCTS — COMP/OP AGG -- $1,000,000 LOC PROFESSIONAL LIABILITY $1,000,000 ECT —$1,000,000" OTHER: PARTI COMB E L 7 AUTOMOBILE LIABILITY Ea accrdant ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED e ODILY INJURY (Per acadent)""""HIRED ONLY AUTOS HAUTOS NON-OWNED67�AUTOS ONLY ONLY Per ecr dent NOT PROVIDED WHILE IN HAWAII UMBRELLALUIB OCCUR EACH OCCURRENCE ......... ......... EXCESS LIAB CLAIMS -MADE IAGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A OTHER SER TATUTE EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N E.,L, EACH ACCIDENT " EXECUTIVE OFFICERIMEMBER E.L. DISEASE SE —EA EMPLOYEE EXCLUDED? (Mandatory If yes, describe under DESCRIPTION E.L. DISEASE— POLICY LIMIT OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Non Certified Instructor of: Country Western 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 The City of EI Segundo, its officers, officials, employees, agents, and S A O TH, i�WBOVE DESCRIBED POLICIES BE CANCELLED BF-IFUHE volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 339 Sheldon St ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Owner/Manager/Lessor of Premises 2 -"- "!I I/ 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: M1 RPG0000000500200 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 anization s The City of El Segundo, its officers, officials, employees, agents, and volunteers 339 Sheldon St El Segundo, CA 90245 Named Insured: Thomas Hickey DBA: Tommusic DJ Services Information re wired 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, (_) 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 # ricertify 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 pjovisions or the greVment will automatically become void.. Signature of Appli Print Name Agreement for: Dated: Reviewed by Date I `