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PROOF OF INSURANCE (2024) CLOSED
TE CERTIFICATE OF LIABILITY INSURANCE DA07/17/20224 ) 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 pollcy(les) 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 NAME` _ 9035 WADSWORTH PKWY STE 3820NA(800) 747-9673 ��C N(03) 422-1276 WESTMINSTER, CO 80021-4541 1 � , Islovens c0mamoteam,com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Company _ 16691 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURERB: ITS PARTICIPATING MEMBERS: City of El Segundo INSURERC: _ 350 MAIN ST hINSURERD: EL SEGUNDO, CA 90245-3895 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: GAS148683 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 TYPE OF INSURANCE AODLS BR POLICYNUMBER POLIDYEFP FOLICYXP LTR INSR� WV4 MM/DDIYYYY PAWDD/Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 }( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300,000 PREMIBES Pe aa0Urranael CLAIMS -MADE ❑X OCCUR MED EXP (Any one parson) $10,000 PAC 4725036 12:00 AM 08/23/ AM A X HOST LIQUOR LIABILITY INCLUDED �- ' 12:00 AM 12:01 AM PERSONAL & ADV INJURY $1.000,000 GENERALAGGR50ATE $1,000,000 GEN'LAGGREGATE LIMITAPPLIES PIEM ', PRODUCTS- COMPIOPAGG$1,000,000 °X POLICY JEDT, Lac COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ee aaeMeal _ _ ANY Aura BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per AUTOS AUTOS AC (dent PROPERTY DAMAGE (Par ea0donl HIRED AUTO NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE m EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION $ 08/22/2024 08/23/2024 EACH OCCURRENCE $1,000,000 q Professional Liability PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 DESCRIPTION of OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Covered Activities: Songwriters Panel Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATE HOLDER UANk;tLLAI IUN Proof of Insurance SHOULD ANY OF THE ABOVE DESCRIBED. POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Tl,%,& C 4Vp, -ruLv v ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEER AN CALIFORNIA EVIDENCE OF LIABILITY INSURANCE a Y Mercury Insurance Company P.O, BOX 10730, SANTA ANA, CA 02711.0730 AGENCY: PENINSULA GENERAL INSAGY. (310) 53e-2533 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE CAAP0000043211 06126/2024 12/26/2024 YEAR MAKE VIN 2023 VOLKSWAGEN NAMEOINSUPED __. ADDITIONAL DRIVERS ROBERT BONF*L: —01 TO REPORT A CLAIM,Ioaso c,al$ (000) 003.3724 For access to ROAOSME ASSISTA904 ONLY, please call 11166 6$194470 This gnsvraraao conwpllaswi(2a CVC tt0El3 art' t0 41t9 S NAIC Pal27E:f3 R fold In half horn A THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. Thrs card must be carala-d In the I'nsun34 motor vshtdo for pmdiyc ri upon dam'snd„ Any alferallan vAl YOU this card. Any binder or policy Iastaod thereon is Valid if ahoy chdck, money order, credit urge, ACH, or other Ran -cash mothad of payment Is not honored when first presented. YOU HAVE AN. C • Notify the police immediately. • Wdle down names, addresses, telephone numbers, ddverllcense numbers, and license pints numbers of all persons Involved and witnesses. • Please note any damage to other vehicles and lake photos If possible. • Do not admit fault. Do riot discuss the accident with anvane excenl vour aaenl. O 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: (_j 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 ins rance 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 # ( I certify that, in the performance of the work set f `rth 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 worker' compensation provisions of Labor Code § 3700 I must immediately comply with tho isions or the agreement wili automatically become void. * , —57 Print Name -- Date Signature of Applic t - Agreement for: Dated: Reviewed by: