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PROOF OF INSURANCE (2026 - 2026)SOUTBAY-48 IT GMA, R,Qj,_, A�ORO CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 7/30/230/2025mmmmmm 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 INSURED provisions _ .._ WWWWW p r be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on g n (s).. this certificate does not confer rights to the certificate holder m lieu--of-such of such endorseme _ _............. ......._ ___ ..m ........ PRODUCER NAME .. ............ PHO World Insurance Associates, LLC (AtC, N 64 Portsmouth Ave ABL a"Exll61D) 772-4781 IL Exeter, NH 03833C05, INSURED South Bay Sprouts LLC 1603 Aviation Blvd Redondo Beach, CA 90278 COVERAGES CERTIFICATE NUMBER., ._ ................._...,.._ REVISION a,1ON NUMBED......,. 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, INs EXCLUSIONS AND CONDITIONS OF SUCH nPOLICIES. IPOLICY NUMBER LIMITS SHOWN MAY HAVE BEEN PAID CLAIMS LTRTYPE OF INSURANCE POLICYEXP LIMITS l 1 A X I COMMERCIAL GENERAL LIABILITY I EACH OCCURRE9CE ,S ... 1 "� occuR 5077 2734-01 7/3/2025 7/3/2026 CAMAGL rya RENTED 300,000 CLAIMS MADE X� �.'"'.E£IS;� (ep 5,000 .PESON �Ayao7a Ia��t�) 1 000,000 ----------------- CNLA"Ot"i3E„tl".,%TT"OLIMITC!, APPLIESPER: �L.NFFALA''L-nA0006 �dY " .„, .. I X PON,.19„^,'Y I JECT LOC . ;F"��"1V.b,8'COMI fCPN..A"C,.r.._......... ...'000,000 ...... ._ ..... OTHER COMBINFD .._ ANY AUTO ... �m..�. BOS.11k Ihl,d'INGLL LIMIT $ t�'� ��>rrti�ntS RY (Pergttr an) AU AUTOS ONLY � _ .OWNED I AUTODULED BODILY IiW,gkJFiY (Per c .kd tsl),! „_,_ A�IiS ONLY �.._ ALiI'NfJ'C.Y (mr1 p"aM 1Dk AhrbAG.P.. . _ $ .... .. ........­ _.­­­­­­_­...1 � ---_._-. j UMBRELLA LIAB I OCCUR CFn t741.kWRLNCP;.... ._ _.. EXCESS LIAB CLAIMS MADE AGGREGATE DED TION $ ee -. RETEN I _. .....--^............................... .�.,.. .... ............_ ......... WORKERS COMPENSATION AND EMPLOYERS' LIABILITYPER C%TP1 Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE 6 L.ACM9 Ait,GIDLN'6 $ _ FFId.",'ER/MEMBER EXCLUDED? � N / A i ry ) f ,. EALM�?i.OYEE $ ... A.. c'RIPTI N 01F O E &DIRtis—kow t or US2 5f924.01 '__...._ 7d312025 f 713/ 4 6 L 01 E POLICY u crY e IMI f _ 100,000 I _ _ _ DESCRIPTION Of OPERATIONS f LOCATIONS a VEHICLES (ACORD IGI, Add6tional Remarks Schedt te, maybe attached if more space is required) (2025) Gymnastics: Any Person or Organization including certificate holder is additional Insured if written signed contact to such exists prior to loss subject to form indicated above In General Liability Section, (2025-2026) The City of El Segundo, its officers, officials, employees, agents, and volunteers is additional insured if written signed contact to such exists prior to loss subject to form indicated above in General Liability Section. The City of El Segundo its officers, officials, employees, agents and volunteers 350 Main St El Segundo, CA 90425 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - BY WRITTEN N CONTRACT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization with whom you have agreed to add as an additional insured by written contract but only with respect to liability arising out of your operations or premises owned by or rented to you. GL 00008 00 (04/09) 'rCEMPER Auto COMMERCIAL Customer Service: (800) 722-3391 South Bay Sprouts LLC 125 28th St Manhattan Beach, CA 90266 Kemper Auto Commercial 11700 Great Oaks Way, Suite 450 Alpharetta, GA 30022 Underwritten by: Infinity Select Insurance Company Claims Service: (800) 353-6737 COMMERCIAL AUTO DECLARATION POLICY NUMBER: 50022082301 POLICY PERIOD: 08/24/2025 To: 02/24/2026 This policy is effective no earlier than the date and time on which the application is accepted by the Company and shall expire at 12:01 a.m. on the last day of the policy period shown on the Declarations Page. If the policy is cancelled for nonpayment, it may be continued with or without a lapse in coverage, contingent upon valid payment and in accordance with our underwriting rules. The following coverages and limits apply to each described vehicle as shown below. Coverages are defined in the policy and are subject to the terms and conditions contained in the policy, including amendments and endorsements. No changes will be effective prior to the time changes are requested, Deductible # Year Make / Model VIN Number COL / COM / FTC 1 2015 NISSAN - NV200 2.5S 3N6CMOKN6FK728379 1000 / 500 / N/A COVERAGES - LIMITS OF LIABILITY PREMIUMS FOR VEHICLES THE COVERAGE IS APPLICABLE ONLY IF A PREMIUM IS INDICATED VEH 1 BI/PD Liability $1,000,000 CSL 2786 Uninsured Motorist - BI $30,000 each person $60,000 each accident 54 Comprehensive 82 Collision 300 Roadside Assistance Five Disablements/annual 13 term Medical Payments $5,000 , 35 Rental Reimbursement $40 per day $1,200 Per occurance 35 Any Auto Bodily Injury 443 Any Auto Property Damage 142 Uninsured Motorist - PD 0 PREMIUM BY VEHICLE: 3,890 TOTAL VEHICLE PREMIUM(S): $3,890.00 FEES: $180.00 "see reverse for fee schedule ENDORSEMENTS MADE A PART OF THIS POLICY: TOTAL POLICY PREMIUM: $4,070.00 50461POL04, 50461AE201, 50000CDD01, 50000RBE01, 500BAE01, 50461AAE03, 50461ADE02 This Policy provides reduced liability coverage limits when an insured auto is being operated by a regular permissive driver who was not disclosed on the policy application or otherwise as a driver to be covered by this policy, or was not disclosed within (30) days after becoming a driver subsequent to the date of application. Liability limits drop to the minimum California Statutory Liability Limits which are $30,000 for Bodily Injury per person, $60,000 for Bodily Injury per accident, and $15,000 for Property Damage per accident, See PART A -LIABILITY, ADDITIONAL DEFINITIONS USED IN PART A ONLY, Paragraph 1.13 and PART A -LIABILITY EXCLUSION 27. FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE COVERAGE OR MAKE A CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. SEE REVERSE FOR ADDITIONAL INFORMATION 50400DCPG04 Page 1 of 2 AMEND DATE: 08/24/2025 ENDORSEMENT: 2-1 Additional Information: Agency Information: THE LIBERTY COMPANY INSURANCE BROKERS, LLC 5955 De Soto Ave Ste 250 Woodland Hls, CA 91367-5190 Please mail all inquiries to: Kemper Commercial Auto 11700 Great Oaks Way, Suite 450 Alpharetta, GA 30022 Please fax all inquiries to: (877)722-3391 DRIVER INFORMATION: # DRIVER NAME EXCL SR22 1 Paige Negrete Yes No 2 Carson Breen No No VEHICLE LOSS PAYEE/ADDITIONAL INTEREST INFORMATION: VEH# NAME TYPE ADDRESS CITY STATE ZIP RATING CRITERIA: VEH# DRV# DRV VEH PERSONAL VEH GARAGING STATED VALUE VEH VEH PNTS GVW USE USE ZIP (INCL: ADDL. EQUIP STATED VALUE) RADIUS BODY 1 2 0 6000 NO H 90266 $13,000.00 500 404 POLICY LEVEL INFORMATION: PAID -IN -FULL: YES ENO PHYSICAL DAMAGE ONLY: YES Q NO CDL DISCOUNT: YES Q NO PRIOR COVERAGE: ❑x YES ❑ NO BUSINESS EXPERIENCE: ❑ YES Q NO STATE FILING: ❑ YES 0 NO FEDERAL FILING: []YES ❑x NO CGL OR BOP DISCOUNT: ❑ YES Q NO RATED OCCUPATION: Gymnastic Instructor ADDITIONAL DRIVER: EYES NO OCCUPATION CODE: D02 For Personal Use coverage, refer to 'Rating Criteria" for each vehicle listed above. PAY PLAN OPTION: 16.67% Down Pay - 5 Installments SCHEDULE OF APPLICABLE FEES, - DESCRIPTION AMOUNT DESCRIPTION AMOUNT Vehicle Fee - Distributed $30.00 Blanket Additional Insured - Distributed $150.00 50400DCPG04 Page 2 of 2 AMEND DATE: 08/24/2025 ENDORSEMENT: 2-1 -- »e."„,..me„µ. — 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: Ihave 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. 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'1-*IACf s" iI UL, Salic lumber Expiration Date g S Phone # wa µ Name of Agent � �" (--_) 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 agreement will automatically become void. Signature of A licant Date s Print Name t Agreement for: Dated, Reviewed by: Policy Viewer Inception Date 07-19-202.5 Regfunal Office Greater Bay Area SOUTH BAY SPROUTS LLC Explratlon Date 07-19-2026 Field Service, O9fl,D NA - SAN FRANCISCO Quote ID 803334115 1603 AVIATION BLVD,REDONDO BEACH, CA 90278 AnpdveMrY Rating Date --- Policy Number 9363599-2025 Coverage Period :tYI-19-2025 to 07 19 20216 P Policy Details CONTACT PAIGE NEGRETE PRIMARY BUSINESS PHONE (951) 454-4352 primary Contact Info CELL PHONE (951) 454-4352 EMAIL paigeCCd—thbay,prn As cam Vl— r1151re! cail0:aCC.F...- Legal Names SOUTH BAY SPROUTS LLC Tar. Type CONTINUOUS COVERAGE State Fund Years 2 Est.. Annual Pwni.m $778.00 Min.— Prern§um $500,00 Entity 7 - OTHER Loss Atuni slz Reports -- Broker Details Brokerage Name AMWiNS ACCESS INSURANCE SERVICES LLC Phone (968) 693-7892 Address 2235 MERCURY WAY STE 210,SANTA ROSA,CA,95407 Fax .....,,..--Class Description Effective G 8870 (1) FITNESS INSTRUCTION PROGRAMS OR STUDIOS- 07-19-2025