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PROOF OF INSURANCE (2024 - 2024) CLOSEDCERTIFICATE OF LIABILITY INSURANCE °A0312012024YY) 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 endorsements . PRODUCER The Camp Team 9035 WADSWORTH PKWY STE 3820 WESTMINSTER, CO 80021-4541 CONTACT NAME: AIc° No. Ed : (800) 747-9573 1 AAIC Hop (303) 422-1276 E.,MApL ss, jSteveTascanropteam.com INSURER(S) AFFORDING COVERAGE NAIL S INSURERA r Great American Insurance Company 16691 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND 17S PARTICIPATING MEMBERS: INSURERS;: INSURERC: City of El Segundo INSURERD: 11t W Mariposa Ave EL SEGUNDO, CA 90245 '... INSURER E '. """"""""' INSURERF: COVERAGES CERTIFICATE NUMBER: GAS138943 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. INSF TYPE OF INSURANCE A00t SUBR. POLICY NUMBER POLICY EFF POLICY Eltp LTA INSR WIrVD MMIDDIYYYY MMIODIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE si'000000 �( COMrdERC1AL GENERAL LIABILITY OAAW GE TO RENTED 5300.000 PREMISES E. ncnmer,eo� n$0 CLAIMS -MADE I " Y MED EXP (Any one person) Hoy PAC 4725036 04/13/2024 04/14/2024OCCUR A � x � T LIQUOR LIABILITY INCLUDED PERSONAL 8 ADV INJURY $1,000,000 12:OD AM 12:01 AM _ GENERAL AGGREGATE St,000.000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS• COMPIOP AGG $1.000.000 POLICYEl JEC1LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea aed-4 BODILY INJURY (Per porson) ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per AUTOS AUTOS dC[Idenl HIRED AUTO NON -OWNED AUTOS PROPERTY DAMAGE IPm ad -II UMBRELLA LIAR .1. EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DED F-T RETENTION 5 A Professional Liability PAC 4725036 04/13/2024 04/14/2024 EACH OCCURRENCE $1,000,000 12.00 AM 2:01 AM AGGREGATE LIMIT S1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101. Additional Remarks Schedule, H more space Is requirod) Covered Activities: Musical Performance Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATE HOLDER CANCELLATION Proof Of Insurance 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 Tk" Ca.wLp-Team. ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Yuki Shibamoto ------------------------------------------------- INSURANCE IDENTIFICATION CARD -California Policy Number. 966470002 NAIL Number: 10192 Effective Date: 02/2012024 Expiration Date: 08/20/2024 Insurer: Progressive Select Ins Co 1-800.776-4737 Valued Customer Since 2023 i PO Box 31260 Tampa, Fl. 33 631 Named Insured(s): Yuki Shibamoto i Year Make Model VIN 2016 Toyota Prius V I Form A022 (10/20) I I IF YOU -RE IN AN ACCIDENT Your policy meets the requirements of Section 16056. 1. Remain at the scene. Don't admit fault. 2. Find a safe location, call the police, and exchange driver information. 3. Call Progressive right away, 1 TO REPORT A CLAIM Call 1-800-274-4499 or go to claims, progressive. com. PRV9Rrff1yf KEEP THIS CARD IN YOUR VEHICLE WHILE IN OPERATION. L- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --- - 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: t`) 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. ( ) 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 lute Phone # 41 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 the agreement will automatically become void. Signature of Applicant"" Date 1 9/2024 Print Name Yuki Sbibamoto Agreement for: Yuki Shibamoto Dated: 3 1' _2i Reviewed by: