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PROOF OF INSURANCE (2026),t CERTIFICATE OF LIABILITY INSURANCEY 05/19/2025 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 INSURERS), 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.lf SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandising K&K Insurance Group, Inc. p/cNNo, EXt a/c No 1 800 506 4856 1 260-459 5590 FAX P.O. Box 2338 ( )................... t Fort Wayne, IN 46801-2338 E-MAIL ADDRESS: info@fitnessinsurance-kk.com �....._. PRODUCER CUSTOMER ID: __ INSURER(S) AFFORDING COVERAGE .....--......... NAIC # ................. ....._.. .................... .. .........._._. .._. ...._. INSURED: 2001379775 CP# 3186 INSURER A Markel Insurance Company 38970 .........._..-._.._. _..,......... ..... ......... Victoria K. Sarnia INSURER B INS ...... ............. .,...-._. ........_.._.... m 650 Mariposa Ave INSURER C: El Segundo, CA 90245 INSURER D: ....... A Member of the Sports, Leisure & Entertainment RPG INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 2000668933 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 BYTHE 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP/Y LIMITS LTR INSD ''� WVD (MMI)DYYY) (MMIDD/YYYY) ............... -..... ......... A ...... ,m.... .._.. X COMMERCIAL GENERAL LIABILITY ......�.. X .�............. ......... M1RPG000O000500400 04/11/25 ...... _............,.,. 04/11/26 EACH OCCURRENCE $1,000,000 $ 12:36 12:01 AM DAMAGE TO RENTED PREMISES $ 1 CLAIMS -MADE D OCCUR PM EDT (Ea Occurrence) ,000,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY PROJECT ❑LOC PRODUCTS - COMP/OP AGG.. $1,000,000 PROFESSIONAL LIABILITY $1,000, 000 OTHER: -..._........... �.�.............. LEGAL LIABTOPARTICIPANTS ..... - $1,000,000 . ...... .............SI .._....._ ..........' COMBINED NGLE LIMIT (Ea ------.._. ''.. AUTOMOBILE LIABILITY accident) ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED BODILY INJURY (Per accident) ONLY AUTOS HIRED AUTOS NON -OWNED PROPERTY DAMAGE(Per accident) ONLY AUTOS ONLY EACH OCCURRENCE UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION NIA PER STATUTE OTHER AND EMPLOYERS' LIABILITY YIN E.,L,. EACH ACCIDENT .m.. ANY PROPRIETOR/PARTNER/ EXECUTIVE yy""•••--• ''ryry E L, DI SEASE EA EMPLOYEE OFFICER/MEMBER EXCLUDED? (Mandatory in If yes. describe under .. E.L. DISEASE- POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certified Instructor of: Aerobics, Pilates The City of El Segundo, its elected and appointed officials, employees, and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. Primary and Noncontributory is added via form MGL1574 This certificate replaces certificate # W02957649 effective 04/12/25 The City of El Segundo, its elected and appointed officials, employees volunteers 350 Main Street El Segundo, CA 90245 Owner/Manager/Lessor of Premises CANCELLATION and 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 u law 5 ACORD CORPORATION. All rights reserved. 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 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MIRPG0000000500400 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 Person(s) Or Organization(s) The City of El Segundo, its elected and appointed officials, employees, and volunteers 350 Main Street El Segundo, CA 90245 Named Insured: Victoria K. Sarnia CP# 3186 Information required to complete 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 2 of 2 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 forthe 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 # U 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""" Date Print Name Agreement for: Dated: Reviewed by: