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PROOF OF INSURANCE (2019 - 2019) CLOSEDACCWV CERTIFICATE OF LIABILITY INSURANCE P oAT09/1 /19 09/10/19 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 NAME Sterling Agency Insurance Services PHONEftt,, 800-991-2002 c,Not- 800-991-2024 P.O. Box 12439 A` DARESS Wsterllnq@sterling:agency.com Marina Del Rey, CA 90295 INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A: Scottsdale Insurance ComDany INSURED INSURER B: Sergiu Boerica INSURER C; DBA: Jaguar Tennis Academy, LLC. INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS wS 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 AFFORnED 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. .v........................................................................................................................................................_....... I _._ II TA TYPE OF INSURANCE imcnL Fwvn POLICY NUMBER IINAMMDrD/YYYY1 rMMiODIYYY-f 1 LIMITS LTR A X RAL LIABILITY x CPS2051988 9/11/18 9/11/19 _. _0,000 COMMERCIAL GENE EACH OCCURRENCE � S 2,00 CLAIMS -MADE I X OCCUR ..0 G N°L. AtJGREpp'GaATE LIMIT APPLIES PER r"OLIC'1' l� PED F—] LDC , OTHFR' mmAUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDNON-OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EXCESS LIAR _ CLAIMS -MADE OEDV N RETEN*'IONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETORJPARTNERIEXECUTIVE ❑ OFFIC E RIME MBEREXCLU DE D? NIA (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below PAMAGE 0 RENTED - _.' F ( I .��e�+�� .. � N. $ _ ..,.. 0......w 1..o5 MLD EXP (Any one Pereon)_....... ....... 5 A. 0 .... PERSONAL 8 ADV INJURY S 1 ,000,000 GENERAL AGGREGATE S 1 ,000,000 PRODUCTS - COMPIOP AGG I S 1,000,000 S COMB;NED' SINGLE 'L m� r BODILY INJURY (Per person) S I BODILY INJURY (Per accident) $ ........................... PROPERTY 0AMhG'E S Peer Aeodonl! $ EACH OCCURRENCE $ AGGREGATEPR S H STATUTE I ER ..............................�.,.,. I DE S -EL DSEASE -EAWEM PLOYEE� E V E L, DISEASE - POLICY LIMIT i S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mors apace Is required) CERTIFICATE HOLDER r«y32T19141l!_rirem The City of EI Segundo, its officers, SHOULD ANJ11P OVE DESCRIBED POLICIES BE CANCELLED BEFORE officials,em Io ees, agents, and voluntejTHE EXPIRATION E THEREOF, NOTICE WILL BE DELIVERED 1N P Y g RD OLPR as Additional Insured ORS401 Sheldon Avenue ' EI Segundo, CA 90245 / © 1988-2015 ICYACOR CORPORAT'I'O 'All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CPS2051988 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Opera - Or Organization( ): tions City of EI Segundo, its officers, officials, employees, EI Segundo Recreation Park agents and volunteers 401SheldonSt EI Segundo, CA. 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II —Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tions) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 ' California Evidence of Liability Insurance GEIC0 -600-641-3000 +,�e�rfccw.ar� GEICO? GENERAL INSURANCE COMPANY PO BOX 509090 SAN DIEGO, CA 92150-9096 SIC Code: 35882 Policy Number 4277&75929 Year 2002 Make ei Effective Date Expiration Date 02-13-4�9 08-13-19 VIRGINIJA KIRKILIENE aERGIU BOERICA 906 E IMPERIAL AVE APT 1 EL SEGUNDO, CA 90245-2519 Modial Vehicle ID No. EXCR>N Ltt) 1FMNU42F72EB78833 Evidence of Insurance Here are your Evidence of Liability Insurance Cards. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. The coverage provided by this policy meets the minimum requirements of sections 16055 & 16500 5 of 1he Cal romm Due to space limitations on the I D card, only the Vehicle Code, minimum tisbiliiy limits prescribed by lava Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. What to do at the time of an accident. • Do not admit fault. • Do not reveal the limits of your liability coverage to anyone. • Exchange contact information; get year, make, model, plate number, insurance carrier and policy number of all involved. Also, identify witnesses and collect contact information. • Contact the police or 911 if applicable. • Contact GEICO by calling i-soo-841-3oo0 or visit geico.com to report the accident. U -4 -CA (11-09) 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 EI Segundo. Policy No. U 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # (_?U I certify that, in the performance of the work set forth in the agreement with the City of EI 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 09/10/2019 Agreement for: 1A Dated: Reviewed by: 441—