PROOF OF INSURANCE (2007) CLOSEDSKM
CERTIFICATE OF INSURANCE 1305708
ISSUED1IDDI
12/02/01/00 6
PRODUCER PHONE (A /C) : 1- 800 - 648 -6406
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
K & K Insurance Group,
1712 Magnavox Way
P.O. Box 2338
Inc.
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
Fort Wayne, In 46801
COMPANIES AFFORDING COVERAGE
INSURED
COMPANY A
LETTER NATIONWIDE MUTUAL INSURANCE CO
COMPANY
B
LETTER
JAZZY GYM
3130 W 134TH ST
HAWTHORNE, CA 90250
COMPANY C
LETTER
COVERAGES
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.
NC =NOT COVERED
CO.
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DDNY)
POLICY EXPIRATION
DATE (MWDDNY)
LIMITS (in thousands)
General Liability
12:01AM
12:01AM
General Aggregate
$ 2000
Products- Comp /Ops Aggregate
$ 1000
A
Q Commercial General Liability
FWC0002426400
11/18/06
11/18/07
Personal & Advertising Injury
$ 10001
E] Claims Made El Occur.
Each Occurrence
$ 10001
❑ Owner's & contractors Prot.
Fire Damage (Any one fire)
$ 300
❑
Medical Expense (Any one person)
$ 5
Participant Legal Liability
$ 1000
A
Automobile Liability
Any auto
FWC0002426400
12:01AM
11/18/06
12:01AM
11/18/07
Combined
Single
Limit
$ 1000
Bodily
Injury
er person)
$
All owned autos
Scheduled autos
Bodily
(per accident
$
® Hired autos
F.]Injury
LX] Non -owned autos
PDama g
$
Garage Liability
❑ Excess Liability
Each
Occurrence
Aggregate
Other than Umbrella form
$
$
Workers' Compensation
Statutory
$ Each Accident
and
$ Disease - Policy Limit
Employers' Liability
$ Disease -Each Employee
12:01AM
12:01AM
AD &D $ NC
Primary Medical $ NC
A
Participant
FWC0002426400
11/18/06
11/18/07
Excess Medical $ 25
Accident
Weekly Indemni $ X NC
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /RESTRICTIONS /SPECIAL ITEMS
CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL INSURED
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE
EL SEGUNDO CLUBHOUSE
300 E. PINE AVE
EL SEGUNDO, CA 90245
ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
COMPANY, ITS AGENT OR REPRESENTATIVES.
AUTHORIZED REP SE TATI E
SL39
NOV -2 7_2007 00:09 CITY OF EL SEGUNDO
POUM NOA1111l111 =
Tws l --0111 ANT CMANOp TML POLICY. ►L�AlE pL�A01t f�AlItPU4Lr.
ADDITIONAL. IMUIRED-OMMATED PERSON OR ORDANMTON
This sndorW Mnr WANK lmaarrana VOW" wadi► fho fo W&V4:
III 1 iE1 M gfEM UWUTY COWWE PART
f1f:"MU E
Nlwa�w M�warwr K OISlraaloaMlulaz
CITY OF Q 96"00
300 F PINE AVE
EL OWUNDO. OA 90W
In a way SppWo Stove, ih ►atrWon mgaakW m wripm fhls w4tromms►d will be *two In ft Docmlloa v aplilla s to
fhMurdo emard)
iNFIO IS AN 1Ntumao (Sadon N) is srrNndsd b indYdo as an frMWtd Me pwson or orponilUm shorn in the Schedule
a an O wed but only wM mom to 11al filly o IOV out of Your opsrstiorw at p►rnda waned by or rsr►Nd b you.
CO a a rt m GNI DISK tna+rn.w a www" ONfss► 6".. tae ftp t w t
TOTAL P.02
r
��b
21st Century Insurance
2ISt.com 1- 800 -211 -SAVE
6301 Owensmouth Ave., Woodland Hills, CA 91367
PERSONAL AUTOMOBILE INSURANCE CARD - STATE OF CALIFORNIA
21 st Century Insurance Company
YEAR: 2006 MAKEIMODEL: LEXUS RX 400
INSURED: VIN: JTJHW31UX60029192
Freddy Gomez EFFECTIVE DATE: 03/16/2007
Leslie Gomez EXPIRATION DATE: 09/16/2007
3130 W 134th St
Hawthorne, CA 90250 Rewarding Good Friends REFER A FRIEND TODAYI
IF YOUR FRIEND BECOMES A POLICYHOLDER YOU'LL
RECEIVE $50 IN FREE GASI DETAILS AT 21st.com.
POLICY NO. 1412837
This card must be carried in the insured motor vehicle
and presented upon demand.
'NAIC Code - 12963
Meets the Requirements of Section 16056
POLICYHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12 -01 -2006 GROUP:
POLICY NUMBER: 1614183 -2006
CERTIFICATE ID: 4
CERTIFICATE EXPIRES: 12-01 -2007
12- 01- 2006/12 -01 -2007
CITY OF EL SEGUNDO SC
401 SHELDON ST.
EL SEGUNDO CA 90245
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
tTHORIZED REPRESENTATI PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
JAZZY GYM, INC SC
3130 W 134TH ST
HAWTHORNE CA 90250
M0409
PRINTED : 11 -17 -2006
(RE V.2 -05)
SC