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PROOF OF INSURANCE (2024 - 2024) CLOSED (2)DATE (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 State Farm® 'i�"i Providing Insurance and Financial Services PO Box 23M Bloomington IL 61702-2358 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. Thankyou for choosing State Farm foryour insurance needs. —.....------- ...----------------------------- IMPORTANT - IDENTIFICATION CARDS STATE FARM Stlitefarin CALIFORNIA Stiltelbrm THIS CARD MUST BE KEPT IN THE INSURED MOTOR INSURANCE CARD I A, VEHICLE FOR PRODUCTION UPON DEMAND. State Farm Mutual Automobile Insurance Company PO Box 23N Bloomington IL 61702.2358 INSURED CHAMP CAMP LLC AND MUTL VOL POLICY NUMBER 6158835-D18.75 EFFECTIVE YR 2006 MAKE FORD APR 18 2024 TO OCT 18 2024 MODEL E250 VIN AGENT TATIANA RUIZ MORE 2EE4 C23 PHONE �1'0 NAIC 25178 PRESCRIBED BYVIDO BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS COVERAGES A D100 G250 U Ul IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, addresses,and phone numbers of persons dnvoWd and mAnesses. Also get drover ficonse numbers of persona urwofved and license plate 2.bosalsaates M Veluloles, 2. Cord odmd fault or dds=s the accident wvdh anyone but State Farm or police. 3. Promptly notify your agent, log on to statefarm.comO, or use the State Farm mobile app to hle a claim. For EMERGENCY ROAD SEFMCE use the state Farnnrnabila ap!p, tog on to statefarmcorn, or call 1 77-627-57. EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT OONS77TInE ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy for full name and definition A babulay H frnevgoneyflondServiee U UnarsuredMotor Vehicle C bledr.0avorients L pt yxiraal Daroaayle U1 Unaaaured Motor Vehicle PD D Cominchensive R1 Car dlr.mflf and'fraurl Expenses Z I oss of Earnings G Collltsion, S lhrodr, D naamfrerrneank and Loss of Siaht 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 CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Service information is located on your insurance card. - — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — IMPORTANT - IDENTIFICATION CARDS STATE FARM State&rm CALIFORNIA StitefO m THIS CARD MUST BE KEPT IN THE INSURED MOTOR INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. ,y �Fs, Farm Mutual Automobile Insurance Company ix 2358 Bloomin n it.61702.2350 IED CHAMP CIAO P II MUTL IONEW VOL POLICY NUMBER 615 SM-DIS-75 EFFECTIVE YR 2006 MAKE FORD APR '1+!2024 T OCT '182024 MODEL E250 VIN '00 now AGENT TATIANA RUIZ MORE 2EE4-C23 PHONE'. 10 0>� NAIC 25178 COE ffi Ur BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS COVERAGES A Di00 G250 U Ul IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, aefdr'esses, and phone numbers of persons involved and witnesses. Also gat drver ruoense numbers of persons involved and license plate numberalstales of vehicles. 2. Don't admit fault or discuss the accident with anyone but State Farm or police. 3. Promptly notify your agent, log on to statefarm.com®, or use the State Farm mobile app to file a claim. For EMERGENCY ROAD SERVICE Wee the state Famrrimrnitffe app, log on to statefarmcorror call 1-877-627•a sI. EXAMINE POLICY EXCLUSIONS CAREFUEEY. THIS FORM DOES NOT 0ONS777UTE ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy for full name and definition A Uaob biry H Frnergtnc-y, Road Service U lfninsured Motor Vehicle C WOW lloyarcras L Playsrc rl Wmafic Ul Urmswed Motor Vehicle PD D Coawmfiidiaasnaer R1 Car Rental anti trawlEy4wnses Z loss of Earnings G CtAsfoni S Dearth, and 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 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: