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PROOF OF INSURANCE (2019 - 2019) CLOSEDClient#: 48149 GYMME ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) x/26/2018 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 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: Te ner-Miller Insurance � HONEJ I, 662 FAX, AIC Nati tit 3 0 - Iara . I_ICenSe #OI(07568 E-MAIL INSURER(Sp AFFORDING GE COVERA ADDRESS'. . 2001 Wilshire Blvd., #101 ., .• NAIL# Santa Monica, CA 90403 I14SURERA: Penn Star Insurance Company INSURED INSURER B J. Marvin Campbell INSURER C dba: The Gym Mechanic � INSURER D 4248 Vinton Ave INSURER E : Culver City CA 90232 ' INSURER F ; COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 A BPLI of INSURANCE .!NSR Wv9 POLICY NUMBER LIMITS 109/15/2019 GENERAL LI CPV002294 4 9115/2018 I n ,f l .,r....I l x 1,00 I 0,000 nY!rid t���..iQ',I �.;f...rar w� Al I. Xf .':'r /OCCUR „F E'!NTl!I;f.r t � uu ryro.�, 5100,000 f� CLAIMS -MADE LX' vlai'wrfC'J',:onet,enm Ir,� N 55,000 XI, BI/PDDed:500 PERSONAL &ADV INJURY 51,000,000 ral: PAI A,, ,rl c,nf I::: x21000,000 GEN'LAGGREGATE LIMIT APPLIES PER ' f"I"+'.ii7l.lr:.'('", t';+14'If4`Crl'!'d'SC4�52,000,000 .......� P0[ LOC ..... LIABILITY AUTOMOBILE .-. YP4fta-NNEC: Ifd tk:'�.,.l�el ! dnlr I S.. IS �d...l. _VVHr I, ' SCHEDULED I; w:;�7l i11. t IP4 Y',J4•'"1 it `o.tt rac['irlr;rr1? 5 ,t.GJ.Y"I"�'Y AUTOS NON -OWNED PRiuPFR 7, "r DAM1"a✓;,`E AUTOS IIS UMBRELLA LIAB I OCCUR C /'+r':I l lyCt.: iJf'f:V:, l"B;d;: S .,, ,„........... ...... EXCESS LIAB CLAIMS -MADE AGGREGATE 5 l RETENTIONS DED I WORKERS COMPENSATION i�r, y'I'71N,1frit AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E i'« ;,TrSes ,$E - EA EMI , ;"YEE: I , If yes, describe under DESCRIPTION OF OPERATIONS below II" "fl'!.E P,L;f Pr'II. k- , LAI' I $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as additional insured for Agreement No. 5404 (Repair/Maintain equipment in fitness, rehab, and physical therapy facilities) . CERTIFICATE HOLDER City of EI Segundo Patricia Harada City Clerk's Office 350 Main St EI Segundo, CA 90245 ACORD 25 (2010/05) 1 Of 1 #S86281/M86125 C'ANCELLA'TION 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 fk-j,vA ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TD1 COMMERCIAL GENERAL LIABILITY EPA -1746 (10/2015) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT (OTHER THAN CONSTRUCTION) This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization when you and such person or organization have agreed in writing in a contract, agreement, or permit, that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured or in connection with your premises rented to you. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured; and 3. Only applies to "occurrences" or coverages not otherwise excluded under this policy. B. Status as an additional insured for the person or organization to which this endorsement applies: 1. Commences during the policy period and after such written contract, written agreement or written permit has been executed; and 2. Ends when: a. Your ongoing operations for that additional insured are completed; or b. The lease of premises expires, or c. This policy is cancelled or otherwise terminates, whichever occurs first. C. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization. EPA -1746 (10/2015) Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission, D. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement will not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., EPA -1746 (10/2015) with its permission. PRODUCER I 'E/V,'SON, NORM IIJvAGLNC`r 0,14406 07 2463 TORRANC L L3(',IL) STEP, Aft M E R C U RY IORRIANC'1: C"\90'501 114 5 UR A WC E 7, 0 rA PA lq Y AUTOMOBILE POLICY DECLARATIONS TLI L ['I IONE (3'10) 1'2r+.5bl)(3 IMPORTANT COVERAGE EXCLUSION POLICY NUMBER POLICY PERIOD APPLICABLE TO ALL COVERAGES, INCLUDING BUT NOT LIMITED TO, LIABILITY AND UNINSURED MOTORISTS, PROVIDED NOW OR LATER, 0401 07 00'72'65994 1[),,012f201a! It is agreed that the insurance afforded ny this po!icy PF�NSQNA INSIIRED 8,op$ no� acrn�e I,'� we bene;'I� alany insi,,i4-j or any NAMED IN'SURED D',VTO party claimant,I any Dllc�9Or VCNCI;_v Is bev)q Ijrad Cy R C(:A/IRS -apprated by a pers,)n 4s'W�r ceIof repafdl ass Wvd-rc- fns. 1 NVIJ;'Iv'111d '.AkAlPkI MARAING, Coverage applies only if premium charge is listed below Coverage/Limils are subject to all policy terms COVERAGES LIMITS OF LIABILITY VrHi�Li: DIeSCMPTICR SENAL NU'IABER COSI OR VALUE NE4,'e19S.41 P.UIRCH. DA7C KPJC9 1 1 MSSAIN LEAF SV/Sl. i ICI JBK 4DIR JN1AZ0CP9BTO02420 N 0612011 2 KU" SOUL FV WAG 4X2 4D KNDJX3AEIG7012476 N 0312017 11 RII 'AY E La (I I') , M I )IJI1101wil ➢ivri4r­rs (41), `&YUS AND AIDDIM3N,"d INIERrSfo(II 3,15 LA KAA \40T6RS INANCZ 10,,i50 I-ALKIP'T AVE FOUNTPN VALLPY CA Coverage applies only if premium charge is listed below Coverage/Limils are subject to all policy terms COVERAGES LIMITS OF LIABILITY PREMIUMS NOC-FACTORY EQUIPMENT BODILY INJURY LIABILITY $ 1 0, 0 0 0 $300,000 CIARI CA CAR CAR 12NIS SURED AND AMOUNTS OF 162 i413 INSURANE FOR EAIARE STATED PROPERTY DAMAGE LIABILITY (J FIWIi AII N 168 149 IHEREIN. ITEMS INSURED ARE SUBJECT TO UNIN5URED MOTORISTS BODILY OWURY LAWLITY $ 00 000 $300,000 i 38 1 ITHE DEDUCTIBLE. NINSUREC MOTORISTS BO$ MAXIMUM 3,15 sA 'TJAPE1, PETY DAMAGE LIASILIT), COLLISION DEDUCTIBLE WAIVER 2 2 MEDICAL EXPENSE $5�000 12 9 LEASEILOAN GAP COVERAGE d�p C A I Y 7 REPAIR OR REPLACEMENT CAR COST COVERAGE COMPREHENSIVE DEDUC 101 L CA! 1 `$2;".i(,! C'dtrr""' $250 G'R $ 22 15 CALIFORNIAASSESMENTS OO�YSION Im E $600 '-'/4R2 $500 /\r' $ . ..... 1:9,5 CA FRAUD FEE ROADSi6E Aggiii�4N&E C'I"R2. $7�5 PER OCCuRRENCE ";.' 2 2 CIGA FEE RENTAL CAR BENEFIT S ' 30 PER DAY 30 DAYS 16 16 INTERVENOR FEE ENDORSEMENTS ATTACHED TO THE POLICY PREMIUMS PER CAR U-10 06/2016 U -45B 720 573 POLICY FEE TOTAL PREMIUM 1 294 7(", IMPORTANT INFORMATION 1.o' 1¢'4i is d d'- c" 11 a I ri � c I 's 1:.11c chanq'es' r( -qu(-.0,110d tc.,I: t -1!C: I -P-1 ��y pc' I:'I I1 yj 01.1i aul_oiTiob]e �noijL—II.P1 I�� 'IiUl co'-.1'sCS nIri 1�1,,10:>/201,9, 3, p C' 1 i. c y VJ i C c ci rn f i J d y i i p a e i. e qi i t 11 ri a1"1 d a I 1 1, 1 t S a I" N c '�'l I 0' 1 r 1: 11 � A 1) It, C, I I I s 111•,11.1 C c.' R e n c, you :�I­IV n.rcke.j: 'm' abo,,e 1ti4' DIJE DATE NEXT 1 Vc, 1 1 Pc5 Y, 1 2 94 NIONL I o o i i 43 r , I if'I 1(.7,%01 1. P 1 4 2 0 13 t3 $4?',) 00 6 . 0 D 11 14 2 () 1 L',>Acnc Pa V - L'. F'.!,' 2 1 ?Tr2 1) 1/20 1 S $ 2 1'1.4('. I. Pay - PC'I y2._.3. 7b 0 1 /'10 J. 8 $2 _' 1 40 $6 ()0 11 /0 2 2 Il UVR, VIOL, CODE', VIC)T_ DATE 'JDDL, C Cf) E VICIL. T)ATC VWL. COI)r lj!C,i_ DA'T'E 211 13/2 0 0 j%(1c 0',!/l 3 2004 1 4 _-,r A cAR OCC DRV RAT I PRN PTS I SD Mk"MIDL'�SYL PD �IdLrII MI SALV USE � MRC" FIN PERS IFLO, GRP CD MULT1' DOB SIR GO REST AIL AtT DRV I DRY PTS1 STD: Sym symisymlsym� 1 RES POL CH1 DRVi BRK DEV 01 12 7 N 'y' NIS I LF 44 N 'UV,' • 11-1 1963 N Y 1 1 3 00; Iq y KA, SL 54 06 186 ES N 1 H 1961 . N� Y 1- UND: C ROSALES AMOUNT DUE: $ 223.76 DUE DATE: 10/01/2018 MAILING DATE: 09/14/2018 PROIDLIC'ER COPY U-1177 111/20116 Process Date: 09/1312018 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. 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. (_) 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # ( 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 lo,,the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t�ppe prov s1 )4' agreement will automatically become void. Signature of Applicant i:' a u'I` ",.a1'r"'�,1" 1�" Date 10/06/17 Agreementfor: GYM MECHANIC r Dated: _ C Yy Reviewed b