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PROOF OF INSURANCE (2022) CLOSEDA ' ' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 06/10/2021 Y) 021 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 MYERS-STEVENS & TOOHEY 26101 MARGUERITE PKWY CONTACT NAME: A/C,Nr o, Ext : (949) 348-0656 A/C, No): (949) 348-2630 E-MAIL mtoohey@myers-stevens.com; BZuniga@myers- MISSION VIEJO, CA 92692-3203 (949) 348-0656 ADDRESS: stevens.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: United States Fire Insurance 21113 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ITS PARTICIPATING MEMBERS: INSURER B: INSURER C : Champ Camp LLC 12655 Bluff Creek Drive #120 INSURERD: INSURER E: Playa Vista, CA 90094 INSURER F COVERAGES CERTIFICATE NUMBER: USP338824 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 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY GENERAL AGGREGATE $2,000,000.00 PRODUCTS - COMP/OP AGG $2,000,000.00 X COMMERCIAL GENERAL LIABILITY PERSONAL & ADV INJURY $1,000,000.00 CLAIMS -MADE OCCUR A SRPGAPML-101-0720 12:00 AM 12:00AM 0 2:01 M 12:01 AM EACH OCCURRENCE $1,000,000.00 X INCLUDES ATHLETIC PARTICIPANTS FIRE DAMAGE (Any y one fire) $300,000.00 GEVL AGGREGATE LIMIT APPLIES PER: MED EXP (Any one person) $5,000.00 X POLICY F—]PE� F LOC AUTOMOBILE A LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIREDAUTO NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ EACH OCCURRENCE $0.00 GENERAL AGGREGATE $0.00 EACH OCCURRENCE $ GENERAL AGGREGATE $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Kids camps & classes (Beach, Skate, Recreation): boogie boarding, tag, baseball, basketball soccer, arts & crafts, dodge ball skateboarding, swimming Certificate holder is additional insured but only with respect to liability arising from the operations of the named insured within the policy term. CERTIFICATE HOLDER CANCELLATION City of El Segundo 350 Main St. El Segundo, CA 90245 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 Myers -Stevens & Toohey ACORD 25 (2010106) v141120.001 @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD " ' ' ADDITIONAL INTEREST SCHEDULE DA 06110/1o//2021 ) ozl AGENCY CARRIER NAIC CODE United States Fire Insurance Company 21113 POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S) SRPGAPML-101-0720/USP338824 06/11/2021 Champ Camp LLC 12:00 AM ADDITIONAL INTEREST (Not all fields apply to all scenarios — provide only the necessary data) INTEREST ADDITIONAL NAMEANDADDRESS RANK: EVIDENCE: I I CERTIFICATE I I POLICY SEND BILL Los Angeles County Department of Beaches & Harbors INTEREST IN ITEM NUMBER X LOSS PAYEE LOCATION: BUILDING: INSURED BEACH O F MORTGAGEE 13837 Fiji WayVEHICLE: BOAT: WARRANTY WARRAN CO-OWNER OWNER EMPLOYEE REGISTRANT � Marina Del Rey, CA 90292 AIRPORT: AIRCRAFT: ITEM ITEM: AS LESSOR LEASEBACK TRUSTEE CLASS: ITEM DESCRIPTION OWNER LIENHOLDER REFERENCE / LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ex): FAX (A/C, No): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST ADDITIONAL NAMEANDADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL City of El Segundo INTEREST IN ITEM NUMBER X LOSS PAYEE LOCATION: BUILDING: INSURED BEACH O F MORTGAGEE 350 Main St. VEHICLE: BOAT: WARRANTY WARRAN CO-OWNER OWNER EMPLOYEE REGISTRANT ElSegundo, CA 90245 AIRPORT: AIRCRAFT: ITEM ITEM: AS LESSOR LEASEBACK TRUSTEE CLASS: ITEM DESCRIPTION OWNER LIENHOLDER REFERENCE /LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ex): FAX (A/C, No): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAMEANDADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL City of Malibu INTEREST IN ITEM NUMBER X ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BEACH O F MORTGAGEE 23825 Stuart Ranch Rd. VEHICLE: BOAT: WARRANTY WARRAN CO-OWNER OWNER EMPLOYEE REGISTRANT Malibu, CA 90265 AIRPORT: AIRCRAFT: ITEM ITEM: AS LESSOR LEASEBACK rl TRUSTEE CLASS: ITEM DESCRIPMON OWNER LIENHOLDER REFERENCE I LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ex): FAX (A/C, No): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAMEANDADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL City of Anaheim INTEREST IN ITEM NUMBER X ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BEACH OF MORTGAGEE 200 S. Anaheim Blvd. Suite 433 VEHICLE: BOAT: WARRANTY CO-OWNER OWNER EMPLOYEE REGISTRANT Anaheim, CA 92805 AIRPORT: AIRCRAFT: ITEM ITEM: AS LESSOR LEASEBACK TRUSTEE CLASS: ITEM DESCRIPTION OWNER LIENHOLDER REFERENCE / LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ex): FAX (A/C, No): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST ADDITIOD NAL LOSS PAYEE NAMEANDADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER X LOCATION: BUILDING: INSURE BEACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO-OWNER OWNER EMPLOYEE REGISTRANT AIRPORT: AIRCRAFT: ITEM ITEM: AS LESSOR LEASEBACK TRUSTEE CLASS: ITEM DESCRIPTION OWNER LIENHOLDER REFERENCE / LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ex): FAX (A/C, No): REASON FOR INTEREST: E-MAIL ADDRESS: ACORD 25 (2010106) v141120.001 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The above are added as additional insured but only with respect to liability arising out of operations of the named insured during the policy period. ACORD 45 (2009/04) © 1993-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 25 (2010106) v141120.001 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: SRPGAPML-1 01 -0720 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: [4160AI►T5I:1 Zel/e14Ee7:lkl1 "4161MI911 e7:87e1:- SCHEDULE Name Of Additional Insured Person(s) Or Oraanization(s) City of El Segundo 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 organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; B. In connection with your premises owned by or rented to you. CG 20 26 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 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. U 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 # (_�_) 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 th reepe ill automatically become void. 2/22/2018 Signature of Applicant Print Name Trevor Elder (Champ Camp) Agreement for: Dated:l Reviewed by: , $ r" Date