PROOF OF INSURANCE (2026)Generated using Certificial's Smart COI NetworkT1 — Track your Suppliers in real-time at certificial.com/coi
COI ID: Y98M7
' 0 DATE (MM/DDNYYY)
CERTIFICATE OF LIABILITY INSURANCE
10/20/2025
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 Dustin Keeney
,.. . _. m,,, , , , WRIS, Inc. dba Western Republic Insurance Services PHONE 8884671718 F'
$Al NII w ,,,,,.. ..... to 9 N�1,
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19900 Beach Blvd. AnDgr,F s, duslin wr..... ancem°° -----------
Suite F1 INSURER(S)AFFORDINGCOVERAGE NAICk
Philadelphia Indemnity Insurance Company 18058
Huntington Beach CA 92648 INSURER A y
INSURED
Jaguar Tennis Academy, LLC INSURER C:
11650 Lakewood Blvd _- .... ...... ......... ... . ,,,,, �.,
Downey CA 90241 1 INSURER F : n
n Avcn w.+cc ^00T1C11%ATC KIIIRADCD• RFVIRIAN NIIMRFR,
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 ...... .., ,.,. . --- 'ADIYL SU RI .................. 1, ®oduCN ' F POLtlCY EXP L S
LTR TYPE OF INSURANCE POLICY NUMBER IMIMIDDIyY, MMIDDIYYYY
xI COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1 000 000
i�At�ACte 100,000
$
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09111/2025 09/11/2026 � ERsoNAL&ADvwJURY � $ 1,000,000
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ENERALAGGREGATE $ 3,000,000
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OOILY ,INJURY (Per p ,rson) $
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AUTOS ONLY AUTOS
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WORKERS COMPENSATION
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ANYPROPRIETOR/PARTNERIEXECUTIVE
OFFICER/MEM BER EXCLUDED?
N I A
E L. EACH ACCIDENT _ __
(Mandatory in NH)
E,L DISEASE EA EMPLOYEE $ .,
If yes, describe under
LIMIT $
DESCRIPTION OF OPERATIONS below
I
E.L.DISEASE -POLICY
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Those usual to the insured's operations. The City of El Segundo, its elected and appointed officials, employees, and volunteers are named as additional insured
where applicable per the attached PI-GL-005 (07/12). Insurance is primary and non-contributory per the attached PI-GL-005 (07/12). A 30-day notice of
cancellation is applicable per the attached PI-CANXAICH-002 (05/11).
CEIRTIFICA-I.E HOLLttH; t AN1i r rv_AIIVry
City of El Segundo
350 Main Street 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
ElSegundo CA 90245
V ltltftf-LUl9A6.UKU I.VKrVKAI Iv1Y. Au n9FILb 1tl3C1VVU-
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COI ID: Y98M7
Generated using Certificial's Smart COI Network TM — Track vour Suppliers in real-time at certificial.com/coi
Policy Number: PHPA140038
PI-GL-005 (07/12)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
PRIMARY AND NON-CONTRIBUTORY INSURANCE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Effective Date: 03/14/2025
Name of Person or Organization (Additional Insured):
City of El Segundo
SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or
organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury,"
"property damage" or "personal and advertising injury" arising out of or relating to your negligence in the
performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date
shown in the endorsement Schedule.
This insurance is primary to and non-contributory with any other insurance maintained by the person or
organization (Additional Insured), except for loss resulting from the sole negligence of that person or
organization.
This condition applies even if other valid and collectible insurance is available to the Additional Insured
for a loss or "occurrence" we cover for this Additional Insured.
The Additional Insured's limits of insurance do not increase our limits of insurance, as described in
SECTION III — LIMITS OF INSURANCE.
All other terms, conditions, and exclusions under the policy are applicable to this endorsement and
remain unchanged.
Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Policy Number: PHPA140038 PI-CANXAICH-002 (05/11)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR
CERTIFICATE HOLDER
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PROFESSIONAL LIABILITY COVERAGE PART
COMMERCIAL CRIME COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL PROPERTY COVERAGE PART
COMMERCIAL AUTOMOBILE COVERAGE PART
SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS
Al or CH Additional Insured or Certificate Holder...
Address ess
Al Cit of El Segundo T3:�55:0�--Main Street
.......... .�_�
El Segundo CA 90245
The following is added to A. CANCELLATION of the Common Policy Conditions of the above applicable
coverage part:
A. In the event we cancel the policy in accordance with the policy's terms and conditions, we will
endeavor to mail written notice of cancellation to Additional Insureds or Certificate Holders,
shown in the above SCHEDULE within the time frame listed below. However, failure to mail
such notice shall impose no obligation of any kind upon us, our agents or representatives.
1. 30 days before the effective date of cancellation if we cancel for any reason other than for
non - payment of premium.
As respects Additional Insureds, the above cancellation provision applies only when the
Additional Insured shown in the above SCHEDULE is added to the policy by a separate
additional insured endorsement as the CANCELLATION NOTICE TO ADDITIONAL INSURED
OR CERTIFICATE HOLDER does not provide additional insured coverage.
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 Policy Number Expiration Date
Name of Agent 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 I
must immediately comply with ose provisions or the agreement will automatically become void.
Signature of Applicant Date 6/5/25
Print Name Sergiu Boerica
Agreement for:
Dated:
Reviewed by: