PROOF OF INSURANCE (2023 - 2024) CLOSEDA CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
10/06/2023
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
Verifly Insurance Services, LLC DBA Thimble Insurance Services
174 West 4th Street, Suite 204
New York, NY 10014
hftps://support.thimble.com/
INSURED
Combine Academy
CA, 90056
djhoward0920@gmail.com
PHONE
A:
INSURER C :
INSURER D :
THIMBLE https://support.thimble.com/
COVERAGE
INSURER F. hftps://www.thimble.com/check-policy-status/
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
22608
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.
.,,..� .... NUMBER MO D MO —
TYPE OF INSURANCE _.-. - ......... POLICY ... _ ..... ... .......
ILTR --- --- --- ............. ADDL S1.II'3Ft .................... POLICY EFF POLICYE3fP........_ LIMITS
X COMMERCIAL GENE LIABILITY
23
3
CLAIMS -MADE X
2:00 PM
11:59/PM
.. I sS�
41p'4 5�
PDT
PST`
MED EXP An one erson)
$ 5,000
A
N
N
IBL-PKLLG2Y89
note
PERSONAL & ADV IN JURY........$.
1,000,000
- ....
one
.....
-
GEN'L AGGREGATE LIMIT APPLIES PER:
expiration
GENERAL AGGREGATE
$ 1,000,000
PROJEC-
X POLICY PRO. LOC
date below.
PRODUCTS - COMP/OP AG ..�1
$ 1 OOO 000
OTHER:
AUTOMOBILE LIABILITY .
N JMIi'
COMBINED ISINGS I
( Ea a6'rIA'tkrtl0.1.,,,, .
$
....
ANY AUTO
}
BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILY INJURY (Per accident)'
$
AUTOS ONLY AUTOS
HIRED `NON -OWNED
P'ROPERTYDAMAGE
$
AUTOS ONLY AUTOS ONLY
CPeruccodprCp.. ........ _'__
------
$
UMBRELLA LIAR OCCUR
EACH OCCURRENCE
$ mm
_
EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
DED RETENTION $
$
WORKERS COMPENSATIONII
OPER TH-
STATUTE ER
AND EMPLO ERS' L ABILIITY YIN
...
...................... _ ..... ...,
ANY PROPRIETORIPARTNER/EXECUTIVE
pp E.L. EACH ACCIDENT
$
OYFICER/MEMBER EXCLUDED
(Mandatory ' )
E.L.E L DISEASE EA EMPLOYE
Ifyes, describe
DESCRIPTION OF OPERATIONS below
E.L. DISEASE POLICY LIMIT
$
A
Professional Liability - Occurrence
I N
N
IBL-PKLLG2Y89
2:00 PM PDT
11ss PM PST AGGREGATE�ACHOCCURRENCE
-$ --- 1,000,000
------ ._.__ ......$—
�..-----
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired)
*Please note that the insured has purchased a monthly policy that will automatically extend upon
expiration of the policy if the insured pays the appropriate premium. At that time, you will receive a new
Certificate of Liability Insurance, evidencing such extension.
con't on form Acord 101
I[;*:LOVIII111aCi
David Howard
Combine Academy
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
, I,,';,
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: dJflOWard0920 p�imal�.COm
LOC #: 1
ADDITIONAL REMARKS SCHEDULE
AGENCY
Verifly Insurance Services, LLC DBA Thimble Insurance Services
__...,_ ....................
POLICY NUMBER
IBL-PKLLG2Y89
NAMED INSURED
Combine Academy
CA, 90056
djhowardO920@gmaii.com
CARRIER NAIC CODE
National Specialty Insurance Company 22608 EEFPEcIVDATE.
Page 1 of 1
ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
For Roadside Assistance: 800-531-8555
Report a claim, get coverage and deductible information, request a tow from the accident
scene, schedule an appraisal or reserve a rental car using:
usaa.com,
USAA's Mobile App, or
By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or
800-531-USAA.
California Evidence of Financial Responsibility
This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability
insurance remains in force. Keep a copy of the ID card in your vehicle at all times.
You may be required to produce your identification card at vehicle registration or inspection, when
applying for a driver's license, following an accident, or upon a law enforcement officer's request.
FCA1 Rem. 6-13
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY
Name and Address of Insured NAIC 25968
DAVID J HOWARD
25829 SEAGRASS TRL
WILDOMAR CA 92595-7414
DAVID J HOWARD
Insurance company
USAA CASUALTY INSURANCE COMPANY
Policy Number Effective Date Expiration Date
02031 70 64C 7101 2 07/21 /23 01 /21 /24
VeV�eBMake/Vehicle Identifi 20 3
K
This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicle and
named insureds and may provide coverage for other persons and other
vehicles as provided by the insurance policy.
50781-0513 02
— ------------------------- ..a..&....k_ ..__---- __.------------
California Evidence of Financial Responsibility
Keep this card.
IMPORTANT: The California Financial Responsibility
Act (Section 16020) of the Vehicle Code requires every
owner or operator of a vehicle subject to the
requirements of the Financial Responsibility Act to carry
evidence of financial responsibility in the vehicle at all
times. Under vehicle code (Section 16028) every driver
f involved in an accident must provide evidence of
o financial responsibility at the scene. Failure to comply is
I an infraction and shall be punishable by fines,
d impoundment or license suspension.
Additional copies available at usaa.com
CONTACT US: 210-531-USAA(8722)
OR 800-531-U SAA
9800 Fredericksburg Road, San Antonio, Texas 78288
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.
C_) 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
Name of Agent
Policy Number Expiration Date
Phone #
(A 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
g pp vision! ;r tie agreement will automatically become void.
immediately comply p 7 Date 10.23.23
Signature Applicant those ro
Print Name David Howard
Agreement for:
Dated: 10.23.23
Reviewed by:
Combine Contracting and Custodial LLC