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PROOF OF INSURANCE (2024 - 2025)'^ DATE (MM/DD/YYYY) . " CERTIFICATE OF LIABILITY INSURANCE 07/17/2024 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 The Camp Team PHONE FAX 9035 WADSWORTH PKWY STE 3820 ac No, Ellu: (800) 747-9573 /,vc No): (303) 422-1276 WESTMINSTER, CO 80021-4541 E-MAIL ......,���. istevens(a)camoteam.com _.....___......-.. _ ............. - ..�..... INSURER A : INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B : ITS PARTICIPATING MEMBERS: City of El Segundo INSURER C : . 350 MAIN ST INSURER D : EL SEGUNDO, CA 90245-3895 INSURER E: INSURER F : ^^%100A /^_ CC r`CDTICIrATC KIIIBIIQCD• (_AC1AARA3 INSURER(S) AFFORDING COVERAGE NAIC # Great American Insurance Company _ 16691 RFVISION 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 - INS TYPE OF INSURANCE ADDL. SUBR LTR INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS MMIDDM'YY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE 51,000,000 EIERENTED S300,000 X COMMERCIAL GENERAL LIABILITY ococcurrence)PREMMISESS PR l � '.... CLAIMS -MADE OCCUR MED EXP (Any one person) $10.m 08/22/2024 08/23/2024 A X HOST LIQUOR LIABILITY INCLUDED PERSONAL & ADV INJURY S1,000,000 PAC 4725036 12:00 AM 12:01 AM GENERALAGGREGATE 51,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S1,000,000 :X] POLICY POLICY IT,ru T' LOG COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY EacdeI BODILY INJURY ANY AUTO (Per person) . ALL OWNED SCHEDULED BODILY INJURY (Per AUTOS AUTOS accident) NON -OWNED PROPERTY DAMAGE '.. HIRED AUTO AUTOS IPer acciden❑ UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE E _. AGGREGATE DED RETENTION 5 082: 0 EACH OCCURRENCE $1,000,000 A Professional Liability PAC 4725036 0 AM 2:01 AM I AGGREGATE LIMIT S1.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addlllonal Remarks Schedule, if more space is required) Covered Activities: Songwriters Panel Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATF FIOI nFR 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 Tire- Camay Tea+"' ACORD 25 (2016103) © 1968-2016 ACORD CORPORATION. All rights reserved. ThP ACORn names and Innn nrP ranictPrPrl marks of ACORD MERCURY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE INSURANCE_ Mercury Insurance Company P.O. BOX 10730, SANTA ANA, CA 92711-0730 AGENCY: PENINSULA GENERAL INS.AGY. (310) 539-2533 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE CAAP0000089469 07/12/2024 01/1212025 YEAR MAKE - VIN 2019 VOLKSWAGEN IIIIIIIIIIN NAMEDINSURED SEAN A LANE ADDITIONAL DRIVERS REPORTTO -. - r -3724 For access to ROADSIDE ASSISTANCE ONLY. pleasOi call '(866) 510-647& This insurance complies 00 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORMERS' 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' compensatlon, 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 Policy Number Expiration Date Name of Agent Phone # (X) 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 prow sions or the agreement will automatically become void. Signature of Applicant Date 6-26-24 Print Name 13 Agreement for: Dated: Reviewed by: