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PROOF OF INSURANCE (2024 - 2024) CLOSED--------------------- ............... ........ . ...... ............ 9'9'9'9'9 DATE (MMVDOMYY� CERTIFICATE OF LIABILITY INSURANCE 04MQ024 . ....... . .. . .... . --- 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,1130LICIES, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE"TWWEENI HE ISSUING INSURERI$), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE KOLDEk . .................... .. . . . . . ...NIMIP rRTANIf,- If the c—ert'lilicat'l holder Is, ain ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIIO,N 118 WAIVED, subject to the terms and conditions of the policy, certain Policies may require, an endorsement. A statement on this certificate does not confer rights, to the certificate holder In lieu of such, endorsement(s). PRODUCIER INAME,' I'he Carrip Ti earn, ILLC PHfiIVE 8010 747 9573 91 3 03'-42'2- 1 2' 1 6 9035 Wadswvth Parkway, rnfo@ca COM Suite 3820, ...... ...... . ..... I ............ Weslirniinsliar, CO, M)021 - — — --------------- -Ii— ................. . tN$JtJRER A Tex Insurance C -1;il Sjp�, arkaiing prograrn Management line, ClityufEll segundu .................. - — ---- 350 Main Stroot ...................... . . ... . ... . .. ............. El Segundo, CA, 90,245 . ...... ... .......... ............... ----LnURVR I : . . ................... . . . . . . . . .................. COVERAGES CERTIFICATE NUMBER: A-SP SU 24 04-014 3,0,2043 ..... REVISION NUM ER ........................ .... .. THIs IS TO CrPO I "Y "(HAY Of rSIJPANCIC LI.STN,",Irl SEILDW14AVE BFr.+J I SaJFD TO 7He N50,)Qrl110WD AW)VIF FOR THIS P01 IrY F1FRn,1Fj INDICA F1, NOTIAITKI; I ANNING ANY RFQ0RfFMFNTL r�PM OR C114C)l IIO"� (*ANY 6',','ONTRAQ1 OR 01 H)-K l I VA01 kt`SPE4�' I0 VOM C H 3H IS CkK Irl MAY ela,,OR MAY RIERI A IN THL NSURAAKEA� CV 0V T'I"C ')rS(.AteE1rj 19MLN 13 "AJI9JL C, I N'CT 0U4, rI'lL I CRJAI'; EXCLUSIONS MID CONCITIUNS CX SMV lVi,PCIES I IMIrS SHOWN Mke HAVE' BY PAD t,,LANOS . . .............. . . . ... . .... . .......... . . . . . . . ......... . . ... TYPE OF lNSQ8Ayq . AD& POUG-V at F"XKy r .......... ................ LIABIUTY FACH rNMURRENCE 3"J" SP9.99 AN NI BES431.17704VOII'V17001202 041ll 12131/2024 -1-11111-1-111-1-1-11 ...... ........ . ....... X COMME PC At, GE N E RAL I.1 A 51 Ln'y FIIRF DAMAGE TO PREMII�SIES 3,00,0�00.100 GLNM i-IMADE, El OGLUR R NT QNny anape - --------- MED EXPI farry ane p2�2��j 00 X N(k UDES ATHI E11C PAR PCIPANTS n2A DV IN J U KY ?fNERAL, AGGREGAT ............ (31l AGGREGA I E 0.,imrr APPt ikrS l CI)MMID AG,G Is 2f000 0100�00 POLlIGY F-� PRojrc-T F-1 LOG ........ — ---------- - - ---- AUTOMOMILE UASM �SNIED SINGLE Ull (17 a accident) HIRE 0 AIJTOS ANY ALITOI., H EMILY NAURY(Per rwsoro $ ALL 01AINE NON-GWNED AUTUS AtITOS BODILY INJURY (rinract�,Jent) I'l UAPJACA-,� SCHEDIJILEDAUMS -------- . ...... .. .......... . umall LIAS � OCOJIR. 1CLAINIS-11l EACH OCCURRrNCE . . . ..... ......... 11 E 11 A 11 rESS LIAS ACpOR11r.G3ATE $ ...................................... . DEDUClItIBLE --------- $ ..m. mmma—* . .......... VAX&a3RSCXMPENSATCN 1-w S771J AW Pf40PRF70RFARTNERArXF(' I JTNF M 0I??FXU?AIL11*-j4 EXCLUMLY? l Ni NC ACCUll 0AWKWil N,r A 11 yes,, oe.scvbe under SPECIAL PROVISIONS belaw ....................... ------------- . . . ................ . .......... . ........ ..... ''I'll, A Abuse/MallestatIon N IN 8ESGLF1'rNV01 13ill 7 7% IZ_02 01410812024 12f31112024 F,,@& �)cccrrunce: S I010,f)00,00 AqgRegale, S 500,000,00 DESCRIPTION . . ............... OF OPERAT)IONS I LOCATIONS I VEHICLES (Atil . ......... ACORD I l AddRional I S*hadwla, if Mora .............. ............ . . .. space Is mquirad) Liabillity Poky Daftpchblp$G,00 DediurIl hr SodlJfy Injurt, arKI $ 10100,100 per PIrriparty Damage ClIl GO Occurrenc.0 l CG 00 0104 13 aind cornpany's specific larrm Caverage fw Particlil Legarl LablRy rrpq4jirLq 0174! QWNY pjdk;jpkOlt ',Lgns A w*veroriWeil Ml il par kApants 04AD90024 , Vt'1112024� CERTIFICATE IHOLDEIR I Clity f El S09.11d. 350 Main Street D Spoundio, CA, 90245 SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCIELILED BEFORE THE EXPERAnON DATE 7HER9OF, Nonce WILL BE DELIVERED IN ACCORDANCE WIM THE III PROIASIONS, AUTHORIZED REPRESENTATIVE ------ Mark Oil Perna AGENCY CUSTOMER IM A-SP-SiU-24-04-04-302043 L0C# ADDITIONAL �.� ..A..w»w.oW..a ............ _� �__._. ..v .......e._......a..e ____. ...�.... ........ mm-------- . AGENCY NAMED INSURED The CafTip Team, II LC City of El Segundo POLICY iwUMBER BE UPTNVO11,301 170011 02 350 Main Street .0 RRMr"R .............. ........... ... sic- C I ODE .. El Segundo, CA, 902,45 Texas Insurance CMaNxMgM Mrvy I a43EFFECTIVE DATC .......,m...wr aaz ACCIRD CORPORATION. O li loll (2008101)• w w w r:, e registered marks of ACCIRD RWITMWI�— « v U-55mraram. lwm wallmlu 4", .wMallriorommo "I COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER: AH-GA,26,932-006 ISSUED TO GROUP POLICYHOLDER: The Group and Blanket Accident & Health Insurance Trust . . . . ................................ . . . . ....................................... CERTIFI�CATEHO,LDER: City, of Ef Segundo CERTIFICATE NUMBER: US2144036 CERTIFICATE EFFECTIVE DATE-. 08 Apr 2024 CERTIFICATE EXPIRATION DATE, 311 Dec 20,24 BENEFIT PERIOD: Provided treatment begins within 30 days, from the date of Injury, Benefits are payable for 52 weeks from the date of an Injury. The Injury must occur after the Effective Date and prior to the Expiration Date and care must be Medically Necessary. DEDUCTIBLE AMOUNT: COINSURANCE PERCENTAGE: 100% of Usual, Reasonable & Customary Charges, LIFETIME MAXIMUM BENEFITAMOUNT: $25,0100 TIT4_10��WlAgjlll Hospital Room & Board Daily Maximum Benefit Amount., URC Intensive Care Room & Board Daily Maximum Benefit: URC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre -Admission Testing Benefit Arnount., UIRC Outpatient Hospital Emergency Room Treatment Maximum IBeiniefit Amount: UIRC Surgical Benefits Primary S u rge!olns Maximurn Benef] 1, Aimoun tURC Assistant Surgeon, Second Surgical Opinion, Coinsuttation Maximum Benefit: UIRC Anesthesia Maximum Beneft: UIRC Surgical Facifity Maximum Benefit per, Operating Ses6ion: URC Doctor's Visits In -Hospital Maximum Benefit. URC, Office Visits, Maximum Benefit: URC X-ray and Laboratory Maximum Benefit Amount: URC N�ursinig Maximum Benefit Amount: URC a= ] Maximum Benefit Amount (Hospital Inpatient)., URC Maximum Benefit Amount (Outpatient): 'URC Ambulance Maximum Benefit Amoluint, URC Medical Equipment Rental Charges Maximum Benefit Amount: URC Medical Services and Supplies IMaxiimum Benefit Amount URC ((Blood, Blood Transfusions, Oxygeni): Dental Treatment IFor Injury Onil'y URC Maximum Benefit Amount: actual) charges Out -Patient Prescription Drugi Benefit: ACCIDENTAL DEATH, DISMEMBERMENT, OR LOSS OF SIGHT $100010 Principai Sum. 79T45UM =9 The terms shown below shall have the meaning given in this section whenever they appear in this Certificate. Additional terms may be dlefined within the provision to whnch they apply. "Accident" meains a sudden, unforeseeable external event which, (1) Causes Injury to one or more, Covered Persons; and (2) Occurs while coverage is in effect for the Covered Person. i "Benefit Period"' means the period', of time from the date of Injury, as shown in the Schedule of Benefits. "Covered Person" means a person eligible for coverage as identified in the Application for whom proper premium payment has, been made, and who is therefore, insured under this Certificate. ODietluctible" means the amount of Eligible Expenses which must be paid by the Covered Person before benefits are payable under this Certificate. It applies separately to each Covered Pierson, "Doctor"' means a licensed practitioner of the heaping arts acting, within, the scope of his license. Doctor does not include: (1) The Covered Person; (2) The Covered Person,"s, spouse, child, parent, brother, or sister; or (3) A person living with a Covered Person, "Eligible Expenses" means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medic6lly Necessary treatment of an IUnjury. Eligible Expenses must be incurred while this Certificate is in force. P'He", "his" and "li includes "she", "her" and "hers."' "'Health Care Plan," means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under: (1) Group or blanket insurance, whether on an insured or self funded basis', (2) Hospital or medical service organizations on a group basis; (3) Health Maintenance Organizations on a group basis. (4) Group labor management plans', (5) Employee benefit organization plan; (16) Professional association plans on a group basis; or (7) Any other group lemipiloyee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended. "Hospital" means an institution which: (1) Is operated pursuant to law; (2) Is primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis: (3) Is under the supervision of a staff of doctors; (4) Provides 24 hour nursing service by or under the supervision of a graduate registered nurse, (R.N.); (5) Has medical, diagnostic and treatment facilities,, with major surgical facilities; (a) On its premises,- or (b), Available to it on a prearranged basis; and (6) Charges for its services, "Hospital" does not include: (1) A clinic or facility for: (a) Convalescent, custodial, educational or nursing care„ (b) The aged, drug addicts or alcoholics; or (c) Rehabilitation; or (2) A military or veterans hospital or a hospital contracted for or operated by a nationalgovern merit or its agency unless: (a) The services are rendered on an emergency basis; and (b) A legal liability exists for the charges, made to the individual for the services given in the absence of insurance.] "'Hospital Stay"' means a Medically Necessary overnight confinement in, a Hospital when rooim and boiard and genera nursing care are provided for which a pier diern charge is made by the Hospital. "Injury" means badilly hamn whxhi results,-ffirecuy anal in epencien illy isease or injuries, to the same Covered Pierson sustained in onie accident, including all related conditions and recurring Symptoms of the Injuries willl bie considered one Injury. "Medlicall Necessary" or "Meidical Necess ftly"' means the service at supply (1) Prescribed by a Doctor for the treatment of the Inl and (2) Appropriate, according to conventional mieidic�aill piractice for the Injury in the locality in which the service or supply is given, "'Nurse"' means either a professional, licensed, graduate registered nurse (RN,) or a professional, licensed practical nurse (L.P.Ni.). l"Stude+ nit Infirmary" means an on carnpus facility which: (1) Provides medical care and treatment to sick and injured students and faculty; (2) IS under the supervision of a DGC10r; (31) Provides, nursing servlces; and (4) hargies forits services. "Student Infirmary"' does not Include: (1) Medical, diagnostic or treatiment facilities with major surgical facilities: (a) On its premises, or (b) Available to it on a prearranged basis; or (2) In patient care. (No benefits are payable for services, supplies, or treatment in a Student Infirmary. Th' is definition is applicable only to its reference in the, provision titled Additional Exclusions) "Supervised or Sponsored Activity" meanis a Certificatehioilder or School authorized function" (1) in which the Covered Person participates; (2) Which is organized by or under its auspices; which is within the scope of customary activities for such entity "Usual, Reasonable and Customary"' means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a) Usually charged by the provider for the service or supply given; and (b) The average charged for the service or supply in the locality in which the service or supply is received; or (2) With respect to treatment or med icai !services, treatment which is reasonable in, relationship to the service or supply giivein and the severity of the condition. We will provide the benefits described in this Certificate to all Covered Persons who suffer a covered loss which, (1) is within the scope of the DESCRIPTION OFIBIENEFITS PROVISIONS and results, directly and independently I of disease or bodily infirrirl from an Injury which, is suffered in an Accident; (2) Occurs while the person is a Covered Person under this Certificate, and (3) Is within the scope of the risks set forth in the DESCRIPTION OF HAZARDS, provisions. Full Excess Medical Expense: If an injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, we will pay the Eligible Expenses incurred,, subject to the Deductible Amount and Coinsurance Percentage (if any), that aire in excess of Expenses payable by any other Health Care Plan, regardless of any Coordinaboin of Benefits provision contained in such Health Care Plain, The Covered Person must be under the care of a Doctor when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury: (1) While thie person is inisiured uind;er this Certificate; or (2) During thie Benefit Period stated on the SCHEDULE OF BENEFITS, The first Expense Must be incurred within the time frame shown on the SCHEDULE OF BENEFITSi, The total of aill medical benefits payable under this Certfficate Is shown on the SCHEDULE OF BENEFITS: and (1) Siubject to the specific maximums shown on, the SCHEDULE OF BENEFITS; and (2) Subject to compliance with the reiquirement, set or in the Llmitatlons section of this, Certificate. Eligibility: Persons eligible to be insured under this Certificate are those persons described as an ELIGIBLE CLASS on the Application. This incluid�es, anyone who may become eligible while this Certificate is in force. Effective (patios: A Covered Person wwilll become ani insured under this Certificate, provided proper premium payment is made, on the latest of: (1) The Effective Date of this, Certificate; or (2) The day he becomes eligible according to the referenced date shown in the Application. Termination: Insurance for a Covered Person will end on the earliest of. (1) The date he Iis, no longer in an Eligible Class. (2) The date he: reports for active duty in any Armed Forces, according to the referenced date shown in the Application. We will refund', upon, receipt of proof of service, any premium, paid, calculated from, the date active dusty begins until the earl of: o (a) The date the premiiu' earner is fully earned, or (b) The Expiration, Date of this Certificate. This does not iincllude IRieserve or Nat onall Guard duty for trainiii (3) The end of the period for which thie fast premium contribution is made„ or (4) The date the Group Policy is terminated. Coverage, under this provision will end on the earlier of: (1) The date ending the six month period immediately following the last day the Covered Person was actively at work on a full time basis; or (2) The end of the period for which the last premium is paid. HAZARD: SPORTS COVERAGE Subject to all other provisions, of this Certificate, coverage is provided for a Covered Person while he is: (1) Taking part in: (a) A regularly scheduled athletic game or competition; or (b) A Ipractiice session, for an athletic team or cllub; (2) Traveling to or from: such a game, competition or practice session provided hie is: (a) Traveling with the athletic team or club; and (b) Under the direct and immediate supervision of: (i) The athletic team or club; or (il) nl adult authorized by the athletic team or club; or (3) Traveling directly, without interruption. (a) Between his home and a scheduled game, competition or practice session; (bi) In a vehicle which is (i) Designated or furnished by the athletic team or club; (0) Operated by a propedly licensed, adult driver, or (III) Under the direct supervision of the athletic team or club; or (c) In a vehicle uather than that described in (3)(b) when: (i), Operated by a properly liicensed driver; and, (iii) Travel time does not exceed an hour each way. Travel time includes the time: (i) To or from home, a schoduiled game, competition or practice sessioni; (fl) Before required attendance time; (inli) After the Covered Person is dismissed; aind (iv) After the Covered Person completes extra dlui:tiesi assigned by the School Covered athletic games or competition are shown on, the Schedule of Bienefits. Injuries which result over a period of time (such as blisters, tennis elbow, etc.), and which are a normal, foreseeable result of the spout are not covered. Unless otherwise stait�ed, we will pay benefits for a covered loss, only once, even if coverage was provided under more than one Description of Hazards. BENEFIT - MEDICAL EXPENSE We will; pay, Ellgible Expenses for a Covered Person's Injury, subject to the Deductible Amount and Comsuranot Percentageif any, shown in the! Schedule of Beniefits. Eligi�ble Expenses are, those incurred for. (1) Hospital Room and Board — charges for the most common semi private daily roorn rate for each day of the Hospital Stay, up to the Maximum Daily Benief t Amount shown in the Schedule oif Benefits for Hospital Roorn and Board. (2) Intensive Care Room and Board - charges for each day of Intensive Care Unit confinement, up to, the Dially Maximum Beriefit Amount shodule of Benefits for the Intensive Care Room and Board benefit. This payment is in lieu of Payment for the Hospital Room anid Board charges for those days. (3) Hospitall Miscellaneous - charges during a Hospital Stay, up to the Maximurn Daily Benefit Amount shown in the Schedule of Beous benefit, Miscellaneous charges do not include charges for telephone, radio or television, extra beds or cots, meals for guests, take home items, or other convenience items. (4) Outpatient Hosplital Expenses - charges by a Hospital for., (a) Pre admission testing (confinement must oiccur within 7 days of the testing); or (b) Emergency room treatment, up to the Maximum Benefit Amount per emergency shown in the Schedule of Benefits for the Outpatient Emergency Room, Treatment bienefit. (5) Surgical Benefits - charges, for (a) A Doctor, for primary performance of' a surgical procedure, up to the Maximum Benefit Amount shown in the Schedule of Benefits per procedure.Two, or moire surgical procedures through the same incision will be considered as one procedure. However, wei will pay up to 1.57 times the surgical procedure charge when more than one surgical procedure through different operating fields are performed during the, same surgical session. (b) A Doctor, for: (i) assistant surgeon duties, (ii) a second surgical opinion„ or (iii) consultation, up to, the Maximum Benefit shown in the Schedule of Benefits for an, Assistant Surgeon, Second Surgical Opinion, and Consultation. (c) Anesthesia and fits administration, up to the Maximum Benefit Amount shown in the Schedule of Benefits, for the Anesthesia benefit. (d) Use of surgical facilities, up to the Maximums Benefit Amount per operating session, as shown In the Schedule olf Benefits for the Surgical Facility benefit. (6) Doctor's Visits - charges by a Doctor for other than pre: or post operative care* �a) For in Hospital vis,its, up, to, thie Maximum Beniefit Amount shown in the Schedule of Benefits for Doctor's Visit — Ini-Hospiital. (b) For offi ce visits, u p to the Maximum Benefit Amount shown 1 n the Scheid ulle of Benefits for Doctor"s Office Visits. Total visits per Inj�ury will not exceed the combined Maximum shown in the Schedule of Benefits for All In-, Hospital aind Office Doctor's Visitsi, (7) X-Ray and Laboratory - charges for X ray, and laboratory tests, up to the Maximum Benefit Amount shown the Schedule of Benefits for thie X-ray & Laboratory �benefit. (8) Nursing Services - Charges for nursing services (other than routine Hospital care) by or under the supervision of a licensed graduate, registered nursie, up to, the Maximum Benefit Amount shown on the Schedule of Benefits for the Nursing berieflit. (91) Physiotherapy - Charges for physiotherapy: (a) While Hospital confinedl, up to the Maximum Benefit Amount shown ini the Schedule of Benefits for the Hospital Inpatient Physiotherapy benefit; (b) As, an outpatient, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Outpatient Physiotherapy Ibenefit, Physiotherapy includes: (a) Heat treatment; (b) Diathermy; (c) Microthern% (d) Ultrasonic; (e) Adjustment; (0 Main ipllaition; (g) Massage therapy and (h) Acupuncture. Total treatment per Injury will not exceed the Maximum Benefit Amounts for Physiotherapy shown in the Schedule of Benefits. (101) Ambulance - from the place where the Injury occurred to the Hospital, up to the Maximum Benefit, Amount shown in the Schedule of Benefits for the Ambulance benefit. '11) Medical Equipment Rental - charges for medical equipment for, (a) A, wheelchair; (b) An iron luingi; or (c) Other medical equipment for which pidor approval by us has, been given; up to the Maximum Benieft, Amount shown in the, Schedule of Benefits for the Medical Equipment Rental benefit. (12) edical Services and Supplies - Charges for medicall services and supplies for: (a) Oxygen and its, administration: (b) Blood and blood transfusions, up to the Maximum Benefit Amount shown in, the Scheduile of Beiriefilts f 101 the Medpply benefit (13) Dental Treatment ® Charges for dental treatment for Injury to a tooth which was sound and natural at the time of Injury, up to, the Maximum Benefit Amount shown; in the Schedule of Benefits for the Dental Treatment benefit, The amounts payable under this Medical Expense benefit could be greatly, reduced if the Covered Person does not comply with the requirements in the Limitations, section of this, Certificate. We will pay the Eligiible Expenses, subject to the Deductible Amount and Coinsurance Percentage shown in the Schedule! of Benefits,, if any, for a Prescription Drug or meid�ication, when prescribed by a Doctor on an outpatient basis. i Prescription Drug means a drug wh,ich: (1) Under Federal law may only be dispensed by written prescription; and (2) Is utilized for, the specific purpose approved for general use, by the Food and Drug! Administration. The Prescription Drug miiust be dispensed for the out patient use by the Covered Person', (1) On or after the Covered Person's Effective Date', and (2) By a licensed pharmacy provider. Benefits are payable up to the Maximum Benefit Amount shown on the Schedule of B.nefits, The amount payable under this benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Get-tificate. BENEFIT A: BENEFITS FOR ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT If, within one-year from the date of an Accident covered by this Certificate, Injury from such Accident,, results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table below. If the Covered Person sustains more than one such Loss as the result of one Accident, we will pay only one amount„ the largest to which he is entitled. Phis amount will not exceed the Principal' Sum which applies for the Covered Person. Loss Loss of Life Loss of Both Feet Loss of Entire Sight of Both Eyes Loss of One Hand and One Foot Loss of One Hand and Entire Sight of One Eye Loss of One Foot and Entire, Sight of One Eye Loss of One Hand Loss of One Foot Loss of Entire Sight of One Eye ................ I -- IW zmw. ,= .0 1 00%i I 00%i 100% Loss, of sight means the total, permanent loss, of sight of the eye. The loss of sight must be irrecoverable by nalurm surgical or artificial means. I Loss, of a thumbi and index finger means complete Severance through or above the metacarpophalaingeal joints (the joints between the fingers and the hand). ilillill I M-lillilli� !:i 11 1 ! "Itililir"i• MMMMMU�� 11 9-0 SO MIN MEIEMEM Is caused by or results from the Covered Person's own: (a) Intentionally self inflicted Injury, suicide or aniy attempt thiereat. (in Missoun this applies only white sane.)I� (b) Voluntary self administration of; any drug or chemical substance not prescribed byi, and taken according to the directions of" a doctor (AccidentAl ingestion of a poisonous substance is not excluded.)-, (c) Commission or attempt to commit a felony; (d) Participation in a riot or Insurrection; (e) Driving under the Influence of a controlled substanice unless administered on the advice of a doctor;, or (f) Driving while Intoxicated. "Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs; I t entall care or treatment other than care of sound, naturai teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Certificate, and rendered within 61 moinths of the Accid'ent; 2Services or treatment rendered by a doctor, nurse or any other person who is: (a) Employed or retained by the Certificateholder; or (b) Who is the Goveired Person or a member of his immediate family; 3, Charges which,: (a) The Covered Person would not have to, pay if hie did not have insurance; or (b) Are in excess of Usual, Reasonable and Customary charges. 4, An Injury that is caused by flight in: (a) An aircraft, except as a fare paying passenger; (b) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or (c) An ultra, light, hang gliding, parachuting or bungi cord jurnping; 5, Travel in or upon: Xf Niff F-M =0 Any benefits payable under this Certificate wffl be limited to the fol�owing: (1) The medical: benefits otherwise �payable under this Certificate will be reduced by 50% ift (a) Excess insurance is provided under this Certificate: and (b) The Covered Person has coverage under another plan providing medical expense beneflt% and (c) The other plan is an HMO, PP,O or siWar arrangement ("PPO Preferred Provider Organization" means an Organization offering health care services, through designated health care providers who agree to pierfoirm these services at rates lower than nonpreferred providers.); and (d) The Covered Person does not Use the facilibes or services of the, HMO,, PPO, or similar arrangement for the provisiion of benefits, The Covered Person's limitation does inot apply to emergency treatment required within 24 hours after an Accident whiich occurred outside the geographic area serviced by the HMO, PPO1 or similar arrangement. IFIN UNIONIST RIT INTIFICIIII 7111 Emma= GRACE PERIOD A grace period of '1-days is granted for each premium due after the first premium, due date. Coverage will stay in force during this Iperiodl unless notice has been sent, in accordance with the POLICY TERMINATION provision, of the intent to terminate coverage under this Certificate. Coverage vwilll end if the premium is not paid by the end of the grace period, PREMIUMS: Premium due dates are the first of every month. Prerniurn, payment made in advance or for more than a one month period will not affect any provisions of this Certificate with regard to chainge. Faillure by the Clertificateholder to pay premiums when due or within, the grace period shall be deemed) notice to us to terminate coverage at the end of the period for which piremiuim was paid. CHANGES IN RATES: We have the right to change the premium, rates, on any premiiurni due date: (1) After the first 12 months insurance is in effect, (2) Coinciding with a change in the coverage provided or classes eligible; or (3) Coinciding with a change in the risks we have assumed), We will give 31 days,written notice of any change kinder (1) above. Notice wHil be sent to the Certificatieholder's most recent address in, our records,, ENiTIRE CONTRACT; CHANGES: This Certificate, the application of the Certificatehiolder (if any, a copy of which is attachiedi), endorsements,, riders and attached papers constitute the entire contract between the parties, if an, application of a Covered Person is required, the application of any Insured, at our option, may also be made a part of this contract. i All statements made by the Certificateho4der or by a Covered Person are deemed representations amid not warranties. No such statement will cause us, to deny or reduce benefits or be used as a defense to a claim unless a copy of the instrument containing the statement is or has, been furnished to such person; or, in the event of his death or incapacity, his beneficiary or representative. After 2-years from the Covered Person's effective date of coverage, no such statement, except in the case of fraud or wiith respect to eligibility for coverage,, will cause such coverage to be contested). No change in this Certificate will be valid until approved by one of our executive officers. This approval must be endorsed on or attached to, this Certificate. No, agent may change this Certificate or waive any of its provisions,, RECORDS MAINTAINED: The Certificateholder or its authorized' administrator will maintain records of the essential features of each Covered Person's insurance under this Certificate. We shall be permitted to examine, the Cerfificateholder's records relating to coverage under this Certificate. Examination may occur at any reasonable time up to the later of: (1) The two yeah period after the expiration of the Certificatehiol der's coverage; or (2) The final adjiustment and settlement of all claims under the Cerlificateholder's coverage, REPORTING REQUIREMENTS: The Certfficateholder or its authorized agent must report to us Iby the premium due datw (1) The names of all persons insuuredl on the Effective Date of this Certificate, (2) The names of all persons who are insured after the Effective Date of this Certificate; (3) The names of those persons whose insurance has terminated; and (4) Additional information irequiiredl as, agreed to by us and the Certificateholder. CONFORMITY WITH STATE STATUTES: Any provision of this Certificate iin conflict, on the Effective Date of this Certificate, with the laws of the state where it is delliveiredl, is amended to, coniform to the minimum, requirements of such laws. NOTICE OF CLAIM Written notice must be given to us within 30 day's (Kentucky - 60 daysi) after a covered loss occurs or begins or as soon ?.s reasonably possible. Notice can be given at our administrative office as shown on the cover page or to our agent, CLAIM FORMS: When we receive the notice of claim, we will send forms for fi�lin�g proof of loss. If claim formisare not sent within 15 days after notice is given, the proof requirements will be met by submitting, within the time reiquired under PROOF OF LOSS, written piroof of the nature, and extent of the loss. PROOF OF LOSS - Written proof of loss must be furnished to us in the case of a claim for loss for which thiis Certificate provides periodic : I payment cointinigent upon continuing loss *thin 910, days after the end of the period for which we are liable. Written proof that the loss continues must be furnished toi us at intervals required by uis, In case of claim for any other loss, proof must be furnished within 901 days after the date of such loss Proof must, in any case, be furnished not more than a year later, except for lack of legail capacity. TIME OF PAYMENT OF CLAIMS: Benefits due under this Certificate for a loss, other than, a loss for which this Certificate provides ins,tal�lments, will be paid immediately upon receipt of due written proof of such loss. Subject to written proof ooss, all accrued benefits for loss for which this, Certificate provides installments will be paid iff oz 11.1011WNF-I tr-9 Y-r to the extent of that payment. Any other accrued benefits which are unpaid at a Covered P,e,rson's, death may, at our option, be! paid either to his beneficiary or to his estate. All other benefits, unless specifically stated oitherwis,e, will be paid to a Covered Person, PAYMENT OF CLAIMS: OTHER BENEFITS. All other benefits will be paid to the Covered Plersor, if he is living, if not, we will pay his beneficiary or his estate. PHYSICAL EXAMINATION AND AUTOPSY - We will pay the cost and have the right to have the Covered Person examined as often, as reasonably necessary while ur expense unless proh ibited bX l�aw, (4 utopisies arei not penniffed to be required in Massachusetts�, Mississippi and South Carolina) SUBROGATION: If we have paid benefits to a Covered Person for Injuries, received in a covered Accident, andin our opinion a third party LEGAL ACTIONS: No action at law or in equity shall be brought to recover benefits under this Certificate less than days after written proof of loss has been furnished as required by this Certificate. No, such action shall be brought more than 3 years, South Carolina: 6 years after the time written proof of toss is required to be furnished. Is M PROOF OF INSURANCE io Named Insured Policy Number: CAA 076908714 TARRETT, 11111111 Effective Date; 11 -01-23 E)Oration Date: 11-01-24 1hiA policy jxo%rdes at laaM the minimum arnountsof hab0ily Ansuranco requived by the CA V EH CODE SECT fON 16055, for the sprici i ied whlcWs and narned insureds , CoCage subject to poticy terms and finnits. PROOF OF INSURANCE fle GILTU Interinsurance! Exchange of the Aulomolb' 4 w Named Insured Policy Nwllttrr ber: CAA 0176908714 TARRETT w. Effective Date: 11-011-23 Expiration Clate: 11-011-24 Thiis policy prcMdva at irast tho miHmum, ornovnts et fiabilly inswancla Poquired by the CA VE11 CODE SECTON 16056 toe the specified vehicles aindnamed' insoreds, Cow, rage subipcit to policyterms and limits. VEHICLES ON POLICY YEAH MAKE VEH M, # 2005 TY'TA P021 TESL Y 1111111 'T E A VEHICLES ON POLICY YEAR MAKE VEH 1,11). 0 20,0:5 TYTA 20,21 -I-ESL DRIVERS ON POLICY "lf T'l HILLm1"I I1 Get your digital proof of insurance & membership, card X>Download the app. Cick,AAA,corn/app''75 Ppy PROOF OF INSURANCE linterinsurance Exchange of the Automobile Club a NAIC # 1559i8 iNamed Insured Rdicy Number: CAA 01769087114 TAR TT, - This ;,)oiicypro,Ades,,at lealsltits mmnAmumamo,afiitsofllialbulityan$tAr,iriice required by the CA VEH CODE SEMON 16066 lor the speci6ed vehidew and named insureds. Coverage subljecl to policy lerrns and ljrnita, VEHICLES ON POLICY YEAR MAKE VFH 1,0, # 4 Mor I TYTA 2021 TESL 1w 'cr w DRIVERS ON POLICY STAR RETI, HOLLISTER VEHICLES ON POLICY #'®rk"40 PROOF OF INSURANCE YEAR MAKE Interinsurante Exchange of the Auitornobille Club,- 2005i TYTA 1 20211 ESiL wimm NAIC # 1559i8 Named Insured Poky Number: CAA 01769087114 STARRETT� �i DRIVERS ON POLICY EffecVve Date: f 1.01-23 Expiration Date: 11-01-24 STARRETT, HOLLISTER This pdicy prWdea at least the mininnurn amounts of fatiflity ansurance required by the CA VEH CODE SEC1110N 16,056 for the specified vehides and narned insureds, Coverage rubjecl, to policy Wins and limits, 564 08: 11 WO FAAMA 2GZIW, rAMP3 �0 �,-, �*IA U .07-INIMIZ C_) 11 have and will maintain a cerfificate of consent of self-inslure 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 Ill Segundo. WO 1171 of the work for which the agreernent wfthi the City of El Segundo �s executed. My workers' compensation insurance carrier and policy number Carrier Policy Number Expiration Date Z=� Agent Phone 4: ()Z I clerUfy thait, in the performance of the work set forth in the agreement with the City of Ef Segundo, I will not empioy any person in any manner so as to become subject to, the workers' compensation laws of Cal�ifomia, and agree that, if I should become subject to the workers"' comipeinsatioin provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement wilill automatically become void, 04/12J24 Signature of Applicant VV*&L��L, Date Print Name Hollister Starrett Agreernient for: 9 =0 0 Reviewed