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PROOF OF INSURANCE (2024 - 2024) CLOSEDDATE (MMIDDNYYY) ACCIOR01" CERTIFICATE OF LIABILITY INSURANCE 1 06/11/2023__, .... . . . . . . ........................... .. ..... 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 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 Myers -Stevens & Toohey & Co,, Inc. PHONE 800-827-4695 949-348-2630 E-MAIL 26101 Marguerite Parkway, ADDRES& mtooh2yownyers-stevensxom Mission Viejo, CA, 92692 ...................... - — — — ­-- INSURER(§) AFFORDING COVERAGE.__ INSURED Sports Marketing Program Management Inc. INSURER A : Texas Insurance Company 16543 Champ Camp LILC INSURER 8: INSURER C 12655 Bluff Creek Drive #120 Playa Vista, CA, 90094 - - ---- INSURER E: ..... . . ....... INSURER F: COVERAGES CERTIFICATE NUMBER: A-SP-SU-23-05-12-276834 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 POUCYIEFF POUCYEXP YPE NSUMNCg. MAR A&" "no . .......... LIM dTS _L1R_ _E=y_KUMffA__ mumm- — MNM= GENERAL LIABILITY EACH OCCURRENCE QQQ—Q_00_'0_0 A y IN BESGLPTNVO1120117001201 06/11/2023 06/1112024 ............... . COMMERICAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES $ 300,000.00 �TQ�nyaqq.pr. . . . ........ . ..... CLAIMS -MADE � X ] OCCUR MED EXP (any on person) Yt 1 UDES ATHLETIC PARTICIPANTS 1C PERSONAL & ADV INJURY $ 0,000.00 GENERAL AGGREGATE U,000 000 0000— GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 F7POLICY r _JPROJECT LOC $ AUTOMOBILE UABLfrY COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) $ . ........... ALL OWNED NON -OWNED AUTO! BODILY INJURY (Per person) $ AUTOS .... ........ BODILY INJURY (Per accident) $ SCHEDULED T715 65E.V PROPERTY . . . ........... AUTOS $ . ...................... . . . . . UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS ILLAB CLAIMS -MADE . ....... AGGREGATE DEDUCTIBLE RETENTION $ .... .. . . ..... $ WORKERSOOMPENSATION TU �T A AND EMPLOYERS . ANY PROPRIETORPARTNERE<ECUTIVE J "IT �E OFFICERNEIVIBEREXCLUDED? L EA.!ACCI.EI!T $ (MandooryinW N/A If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE ................... $ E.L, DISEASE - POLICY LIMIT $ A Abuse/Molestation Y N BESGLPTNV011201_17001201 16/1112023 06/11/2024 Each Occurrence: $ 25.000,00 Aggregate: $ 50,000.00 L DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Attach ACORD 101. Additional Remarks Schedule, if more space is required) Liability Policy Deductible: $0.00 Deductible for Bodily Injury and $ 1000.00 per Property Damage Claim. ISO Occurrence form CG 00 01 04 13 and company's specific forms. Coverage for Participant Legal Liability requires that every participant signs a waiver/release. The certificate holder is named as Additional Insured with respect to (continued on next page) City of El Segundo. its officers, officials, employees, agents and volunteers 350 Main Street El Segundo, CA, 90245 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELFVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. --J, Mark Di Perno ,_�.... ....._............................ ............ AGENCY NAMED INSURED Myers -Stevens & Toohey & Co., Inc. Champ Camp LLC ��.. ...... .... _... �.. POLICY NUMBER 12655 Bluff Creek Drive #120 BESGLPTNV011201 170012,, 01 Playa Vista, CARRIER-....—......��__...........................�..��.................... NAIC CODE........... CA, 90094 Texas Insurance Company 16543 EFFECTIVE DATE: 06.........................,,,,,.,...... ��.....���...�........._.�,.,..,......_ ��..�w�,�..._......����� /11/2023 ............ ADDITIONAL REMARKS ArnRn 75 igni Ainni The ArnRn name and Innn ara ranicferarl marlrc of ArnRn (c iQAA. gnnQ ArnRn rnRPnRATInN All rinhfc rac-ad PCA State Farm® Providing Insurance and Financial Services PO Box 23M Bloomington IL 61702.2358 Stdterarm Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive additional assistance. Thank you for choosing State Farm for your insurance needs. -----.. —--...... ,.....— — — — — — — — — — — — — — — — ....— — — -------- IMPORTANT - IDENTIFICATION CARDS STATE FARM SfafeFaffn CALIFORNIA teArm THIS CARD MUST BE KEPT IN THE INSURED MOTOR s INSURANCE CARD s VEHICLE FOR PRODUCTION UPON DEMAND, State Farm Mutual Automobile Insurance Company PO Box 2358 Bloomington IL 61702-2358 INSURED CHAMP CAMP LLC AND MUTL ELDER, TREVOR & ALYSSA VOL POLICYNUMBER 6158835-D18.75 EFFECTIVE YR 2006 MAKE FORD OCT 18 2023 TO APR 18 2024 MODEL E250 VIN AMMjAYA-MAE 25178 8764-A75 BY THE POLICY MEET'S THE MINIMUM LIABILITY LIMITS 50UU1 IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. G,et somas, addresses, crud phooe members of persons imotvad end witnesses. Also agar driver loenso numbers of potsomr Involved rust Faense plate numbarslrstales of veNdes. 2. Donl odrnit ImN or dis"so the w6dard vAh orryone but Stale Farm or police. 3. Promptly notify your agent, log on to stateform.carrM, or use the State Forth mobile app to file a clam. For EMERGENCY ROAD SERACE one $9 SiMe Fermi oorbilo mpp, tog on to sletelarmeorg or cell 1�77-Q7.5757. EX4441AlE POLICY E%Ci.l MStiONS CA',RE6'if'd.C.YY, THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY How to identify your cove rage. See policy torfu11 name and defin Rion A bablTity H Emergency Road Service El fd incise re f Motor 4dgni fo C Medical Payments L Physical Damage U1 Unirmmed Motor Vehide PO D Comprehensive R1 Car Mental and Travel Expenses Z Loss of Earnings G CoUision S Death,0isrnemberrtremand Lass oh Sioln KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARES OR A PHOTOCOPY OF CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Service Information is located on your insurance card ------ --- —------..-..------..--....... —.,----..._..------j IMPORTANT - IDENTIFICATION CARDS STATE FARM SteF7 CALIFORNIA INSURANCE CARD to- State FarmMutualAutomobile Insurance Company PO Box 2558 Btoomlrrgton IL 61702.2358 INSURED CHAMP CAMP LLC AND MUTL ELDER, TREVOR 6 ALYSSA VOL POLICY NUMBER 6158835-D18.75 EFFECTIVE YR 2006 MAKE FORD OCT 18 2023 TO APR 18 2024 MODEL E250 VIN on AGENT CRISTiAN AMAYA-MAFMNE"2 8764-A75 THE U Ui LIABILITY LIMITS erarn; THIS CARD MUST BE KEPT IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND a. IF YOU HAVE AN ACCIDENT - NOTIFY THEPOLICEIMMEDIATELY 1. Get names, aftesses, and phone numbers of persona Involved and witnesses. Also get drrW kaense numbers of persons imralved and license plate wmbers/strdes of vehfctes. 2 Dorm admd fault or discuss the accident with anyone but State Farm or ponce. 3. Prompt n" your agent, log an to staleform.comG, or use the State Form mobile app to foe a clam. For EMERGENCY ROAD SERVICE use the Slide ratntroohdoapp.Ie onlosletelermeorgor,eell 1477J;t7-SM. EXAMINE POLICY EXCLUSIONS CAREFUf Y. TNIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy forlull name and definition A Uabiey, H Emergency (load Service U Uninsured Motor Vehicle C MedcelPeymems L PhysialDamage UIUninsured Motor Velrcle PD 0 Comprehensive RI Car Reraal and Travel Expenses Z Loss of Eami lgs G Collision S DeethDisnembermentand KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH ITWAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL 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: C___) 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 Cade § 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 # CV 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 �grpement will automatically become void. r -� Signature of Applicant( '"'�° Date 3/13l24 Print Name David Howard Agreement for: CK(WV Camp Dated: Reviewed by: