Loading...
PROOF OF INSURANCE (2024 - 2025)"� ......-,M.. _ .. ......m ....m.. ..... DATE (MM/DDIYYYY) C>RtY _ CERTIFICATE OF LIABILITY INSURANCE 06111 /2024 . ...........THIS CERTIFICATE IS ISSUED AS A .............__ ... -r- ._..................... ._................................... ----e-� E. ......... 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. IMPORTAN:....m...he ertificatl�der is an ADDITIONAL INSURED, the policy(ies must �be endorsed. If SUBROGATION ...............................�...�... T:If the certificate holder ) - ON 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 NAME: _ Myers -Stevens & Toohey & Co., Inc. PHONE 800-827-4695 FA>( 949 348-2630mmmmmmmmmmm .1A Cho -9x11_ ... ..._........... G4 Nam......._........... m E-MAIL S mtoohB m crs,steVenS.con"Im .m 26101 Marguerite Parkway, uo.�� 7 — "- ER Mission Viejo, CA, 92692 &Y4T? _.............�........................ ........ INSURER(S1AFFORDING COVERAGE NAIC # INSURED ..._Sports Marketing Program Management Inc. INSURER A: Texas Insurance Company 16543 ChampCamp LLC.�.........�.�_-�..�.�.�_._.............�...........................�.�.�.-,.. ,__�.............. INSURER B INSURER C 12655 Bluff Creek Drive #120_.......................--......................................................... _....�.�.�.�.�.�_- Playa Vista, CA, 90094 ..... .Rm°�:.....�... ... �.�.�... �............................................�� INSURER E : INSURER F : r_nvt`aert=c rt`RTlF1r1►TE NIIM li:R• A -RP .9E 9_,24»n4-12-Sn27R3 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., INSRCYEXP TYPE OF INSURANCE lMqpAte... VjM SUBR POLX.YEHF I WWA ..... LIMIT _TP_ '.. GENERAL LIABILITY I06/11/2024 EACH OCCURRENCE $ '( 000 000.00 �— A Y IN BESGLPTNV011301^170012 02 06/11/2025 --•••••----•••••--••----••••---- ••• X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES $ 300,000.00 RENTED (Any one 2remisesl CLAIMS -MADE FT�� OCCUR MED EXP (any one person) $ S,OOO.QO X INCLUDES ATHLETIC PARTICIPANTS PERSONAL & ADV INJURY $ 1,000,000.00 ........ GENERAL AGGREGATE GENERAL �..��Q Q,� GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AG G „0 0.00 $2 QQQ2 �Q POLICY PROJECT pLOC $ _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) $ ..............m......... ,........................ ,..._. ALL OWNED NON -OWNED AUTO _.�. BODILY INJURY (Per person) $ AUTOSa.._.,._.,,...__._�.� .............�........... _e„�................_.. BODILY INJURY (Per accident) $ SCHEDULED � PROPERTY DAMAGE ............ AUTOS PerOP i UMBRELLA LIAR OCCUR EACH OCCURRENCE ........$.__ �I —•• °° EXCESS LWB .....CLAIMS -MADE ____ ... $ -........p .......,..-.m AGGREGATE DEDUCTIBLE............. $ .............. RETENTION $ ��.....................�...........................$ ''. WORKERSCONPBJSATION H AND EMPLOYERS'LWBLRY �C.L.�I ANY PROPRIErOPoPARTNERAD(ECUTNE M OFFICERMIEMBEREXCLUDED? E.L. EACH ACCIDENT $ (MardtfaryiiW NIA If yes, describe under E.L. DISEASE - EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.: DISEASE -POLICY LIMIT $ OTHER A Abuse/Molestation Y N BESGLPTNV0113014170012 02 06/11/2024 06/11/2025 Each Occurrence: $ 25,000.00 Aggregate: $ 50,000.00 DESCRIPTION OF UPERAI IUNS / LUGAI IVNS / VtHIGLtS (Attacn AGVHU 1U1, Additional RemarKS SCneaule, IT more space IS requlrea) 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) CERTIFICATE HOLDEN CANCELLATION City of El Segundo. its officers, officials, employees, agents and volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 350 Main Street DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA, 90245 1� / e Mark Di Perno AGENC. ........... —_ �. �..� �....................�............... __...��...�__ ......... �._...._ �...._...m...... ......................m..������ Y NAMED INSURED Myers -Stevens & Toohey & Co., Inc. Champ Camp LLC ....POLICY NUMBER��....................................._�...���....................................... .................................. .......... —m...�..._�......_�. , 12655 Bluff Creek Drive #120 BESGLPTNV011301�170012w 02 Playa Vista, CARRIER....A,._........._.._._...�m��.................�_ m�.................. ......................................................................, CA, 90094 NAIC CODE Texas Insurance Company y16543 . EFFECTIVE ..DATE: 06/11/2024_...._ .............. ADDITIONAL REMARKS arnRn 9S l9m Ainni Tho Af'nRn nnma and Innn nra ranicfararl mnrlrc of ArnRn rni OAA. gnnq ArnRn rnRPnRATInN All rinhfe roc—arf POLICY NUMBER: BESGLPTNV011201_170012_01 CERTIFICATEM A-SP-SU-23-05-12-276834 NAMED INSURED: Champ Camp LLC POLICY PERIOD: June 11, 2023 to June 11, 2024 COMMERCIAL GENERAL LIABILITY CG 2011 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL, INSURED - MANAGERS S O LESSORS S OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Ref: Champ Camp LLC Name Of Person(s) Or Organization(s) (Additional Insured): Any person or organization if required by an insured contract provided such contract was executed prior to the occurrence or offense. City of El Segundo 350 Main Street El Segundo, CA, 90245 Additional Premium: $ Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. However: 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted by This endorsement shall not increase the law; and applicable Limits of Insurance shown in the Declarations. CG 2011 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 State Farm Providing Insurance and Financial Services PO Box 23W 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 StateFaffn CALIFORNIA tateT=t THIS CARD MUST BE XEP'T IN THE INSURED MOTOR INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND, _._....�,�... Stalls Fame Mutual Automobile Insurance Company PO Box 2358 Bloomin on IL 61702-2358 INSURED CHAMP CM'P' LLC AND MUTL VOL POLICY NUMBER 615 MM-018.75 EFFECTIVE MODEL 6 M KE FORD E250VIN APR 182024 TO OCT 182024 AGENT TATIANA RUR MORE 2EE4-C23 , PHONE p 10 0 NAIC 25178 PRFII� YVIAF BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS COVERAGES A t 00 G250 U Ui IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1, Det namos, adciaasas, and phony nu;rri of perewans, involved and w irneaOas. Aiwa got driver Isoansa numbers of Persona inwived and ieanae plate mrmbarad'sini of vol `t clot• 2. Dual adrA frock or dscrZ4 Itnt aooldent wvah ;ati but Stole Farm Of patios. 3, Proari, nwIfy your agent, fog on Lo sta lefamr or iR, air use the Staro Farm made Opp to rile a adaim, Far EM'ERRENCY'RDAU SEWCEuaro she StateFeam,gwohdfa aora.log onto 0clatatri or call t-V740 "f , 00t 1 aE POLICY EXCLUSIONS NS C;AAEFULLY. THIS FORM' DOE'S NOT OONSTrTUTE ANY i"Ai7Y OF YOUR INSURAMW POLICY. How to identify your coverage. See policy for full name and definition A Liahfay H FmenryrrrcyrRamawd'.Servree U UrAismedMotorVehicle C Medical Payments L ftviy of DnrnsgS UI tar+arauaad Mortar Vehicle PO D Caa yamehcna vc R1 nar RLnrnl arwf fiavei rgxpai ses Z I ass of Earnings G coalition S Death, Dtarmmhomi and 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 Emergency Road Si Information is lowed an Your insura nor card. IMPORTANT - IDENTIFICATION CARDS STATE FARM tate S afei�r r CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND. INSURANCE CARD Farm Mutual Automobile Insurance Company rx 2M Blooetin on IL 617(➢2 lED CHAMP C p R� MUTL ICI ",rrr.' VOL POLICY NUMBER 615 8835-DIS-75 EFFECTIVE YR 2006 MAKE FORD APR 18 2024 T OCT 18 2024 MODEL E250 VIN Q AGENT TATIANA RUIZ MORE 2EE4~ �PHjONE I�310 0.8= NAIC 25178 P 'ii VIEIP�+ d BY THE FY91.YC;"f MEETS THE MINIMUM UABdLYTY LIMITS COVERAGES A MOO G250 U Ui IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. fiaai narnat„ twaraessaos. and phone mm�bars of parsons involved and wwltneaaes. Also slat drirar ficanse numbers of persona involved and Manse plate mmsbersvwsaa%ea of vohictaa. furari`t admll fault or 4scuss the acoddant vaAfh anyone but Slate Form or poiioo. 3, PYortapMV� ant, on to �yi afmrrt.ocari or use the Stare Form mr ilh: ai to fdo Oe M. For EMERGENCYROAD SER%CE uaa the 5aara Farmnwh}lo are, No oc to slaloiarmuaoriw arcatf 1 �077427•67 N. EXAMINE POLICYarlo-UVONSCAR FVU Y. Tfwi'S FOFM DOES NOT CONSTInfM ANY PA RT OF YOUR INSUR4MWPOLICY. How to identify your coverage. See policy for full name and definition A tiahiTay H ffnwoemy Read Service U Ummured Motor Vehicle C Medical Payments L MysgAA Danaofle Ul Uninsured Motor vehicle PD D CoaTfeberme RI Cor Bernal and'la,wval Earpr•nses Z Loss of Earnings G Gorman S Drath.oisincraticrmc oast 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 BB ONE CAREIE'IEi R'P'AA PHOTOCOPY A CARD, WI'TTf YOUR VEHICLE REGISTRATIONENEWAL�� OF INSURANCE IN COURT. 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: U 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 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 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 § 370 1 must immediately comply with those ovjsions,or the aggreement will automatically become void. --? f p m, Signature of Applicant Date � t ° Print Name i r r, Agreement k Dated: Reviewed by: