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PROOF OF INSURANCE (2024 - 2024) CLOSED%. T` � CERTIFICATE OF LIABILITY ILIT"" INSURANCE DATE,MMIDDIYYYY) 1 05/03/2024 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 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endoraed. 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 NA E ._ 9035 WADSWORTH PKWY STE 3820 ' %N DEMO (800) 7479573 (303) 422-1276 WESTMINSTER, CO 80021.4541 E-MAIL ennmFss, 1stevens cam team.com @ p INSURER A: � ............. _ __ _......... INB. .. URED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND (NSURERB: ITS PARTICIPATING MEMBERS: City of El Segundo INSURER0 z 350 MAIN ST INSURERD: EL SEGUNDO, CA 90245-3895 INSURERS; INSURER F: INSURER(8) AFFORDING COVERAGE NAIC if Great American Insurance Company 16691 CIOVERAt EIS, CERTIFICATE NUMBER., GAS143133 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 PSI® CLAIMS. Man TYPE OF INSURANCE mmITIT ''AOD SU,B'R POLICY NUMBER POLICY Epp POLICY EXP TR 1NSR D O YY Y MNDYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 k COMMERCIAL GENERAL LIABILITY PRE0.11 TO .5 RED 4300,000 OLAIMS-MADE _X� OCCUR MED EXP (Any one person) $10,000 A k HOST MOUOR LIABILITY INCLUDED k PAC 4725036 05104/2024 12:00 AM 0510612024 12:01 AM .. .. PERSONAL s AD . V INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 M......... PRODUCTS-COMPIOPAGG ............... $2,000,000 ®BN'LA12GREGATELIMIT APPLIES PER: P82lD-, k POLICY €i4,°.1^ LOG DDMBINBD 51NGLe LIMN AUTOMOBILE LIABILITY BODILY INJURY (Per peraan) ANY AUTO ALL OWNED SCHEDULEDIT BODILY INJURY (Par AUTOS AUTOS .an HIRBOAUTO NON -OWNED PROPERTYDAMAGE t II AUTOS r ........................... UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAO CLAIMS -MADE AGGREGATE BEH3....... RETENTION S 06/0412024 05/05/2024 EACH OCCURRENCE $1,000,000 Professional Liability k PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000.000 DE80RIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarka 8ahadula, It more apma Is raqulmd) Covered Activities: Band/Concert The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named insured during the policy period. Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATE HOLDER CANCELLATION Acme time machine 3580 Greenhill Rd. Pasadena, CA 91107 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 Tkz Caw'p T2a4. ACORD 26 (2016103) @ 1908-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Fold here Cut along edge ♦ X Allstate. Please use the printed Insurance Cards below. Please use the printed Insurance Cards below.. California Proof Allstate. If you have an accident or loss: Auto Insurance Card • Get medical attention if needed. Allstate Northbrook Indemnity Company NAIC# 36455 PO Box 660598, Dallas, TX 75266-0598 • Notify the police immediately. Ellen PO, Ronald T PO 3580 Greenhill Rd • Obtain names, addresses, phone numbers (work & home) and Pasadena CA 91107-2140 license plate numbers of all persons involved, including passengers and witnesses. • Call 1-800-ALLSTATE (1-800-255-7828), This policy meets the requirements of the applicable California financial :, logon t0 allstate.com or contact your Allstate agent responsibility law(s), as soon as possible. POLICY NUMBER YEAR / MAKE / MODEL W Smith Ins Sery 967729 605 2021 Hyundai Kona (626) 791-7636 EFFECTIVE DATE 11/08/23 VEHICLE ID NUMBER 1968 Lake Ave #101 EXPIRATION DATE 05/08/24 Rrrrroes e This card must be carried in the vehiclo11 'es vidcuT�`o of insurance. e of Altadena, CA 91001 3038 California Proof of Allstate. If you have an accident or loss: Auto Insurance Card • Get medical attention if needed. Allstate Northbrook Indemnity Company NAIC# 36455 PO Box 660598, Dallas, TX 75266-0598 Notify the police immediately. Ellen PO, Ronald T PO 3580 Greenhill Rd Obtain names, addresses, phone numbers (work & home) and Pasadena CA 91107-2140 license plate numbers of all persons involved, including passengers and witnesses. • Call 1-800-ALLSTATE (1-800-255-7828), This policy meets the requirements of the applicable California financial logon t0 allstate.com or contact your Allstate agent as soon as responsibility law(s). possible. POLICY NUMBER YEAR / MAKE / MODEL W Smith Ins Sery 967 729 605 2021 Honda Odyssey (626) 791-7636 EFFECTIVE DATE 11/08/23 VEHICLE ID NUMBER 1968 Lake Ave #101 EXPIRATION DATE 05/08/24 woAltadena, This card must be carried in the vehicle at all times as evidence of insurance. CA 91001 3038 California Proof of l'lstate • If you have an accident or loss: Auto Insurance Card • Get medical attention if needed. Allstate Northbrook Indemnity Company PO Box 660598. Dallas, TX 75266-0598 NAIC# 36455 • Notify the police immediately. Ellen PO, Ronald T PO 3580 Greenhill Rd • Obtain names, addresses, phone numbers (work & home) and Pasadena CA 91107-2140 license plate numbers of all persons involved, including passengers and witnesses. • Call 1-800-ALLSTATE (1-800-255-7828), This policy meets the requirements of the applicable California financial logon to allstate.com or contact your Allstate agent as soon as possible. responsibility law(s), POLICY NUMBER YEAR / MAKE / MODEL W Smith Ins Sery 967 729 605 2019 Honda Pilot (626) 791-7636 EFFECTIVE DATE 11/08/23 VEHICLE ID NUMBER 1968 Lake Ave #101 EXPIRATION DATE 05/08/24 This card must be carried in the vehicle at all times as evidence of insurance. Altadena, CA 91001 3038 Renewal auto policy declarations Your policy effective date is November 8, 2022 Total Amount Due for the Policy Period Please review your insured vehicles and verify their VINs are correct. Vehicles covered ldetion Number (VIN) Premium 2019 Honda Pilot $1,427.90 �.. 2021 Honda Odyss.ey _ 813.74 �� �_..... _ _ ....... —...�... �_..., _.. ..� .. 2021 Hvundai Kona 890.43 California Fraud Assessment Fee Total* 2.64 $3,134.71 LIM Page 1 of 6 Information as of September 16, 2022 Summary Named Insured(s) Ellen PO, Ronald T PO Mailing address 3580 Greenhill Rd Pasadena CA 91107-2140 Polic number 967 729 605 * Your bill will be mailed separately. Before making a payment, please refer to your Your policy provided by latest bill, which includes payment options and installment fee information. If you do Allstate Northbrook Indemnity not pay in full, you will be charged an installment fee(s). Company See the Important payment and coverage information section for details about Policy period installment fees. Beginning November 8, 2022 through May 8, 2023 at 12:01 a.m. standard time Discounts (included in your total premium) Anti -theft $10.21 Good Driver (20%) $765.32 Distinguished $549.36 Driver Total discounts Discounts per vehicle $1,324.89 2019 Honda Pilot $487.45 Anti -theft $3.84 Good Driver (20%) $339.26 Distinguished $144.35 Driver 2021 Honda Odyssey $397.62 Anti -theft $3.44 Good Driver (20%) $203.44 Distinguished $190.74 Driver 2021 Hyundai Kona $439.82 Anti -theft $2.93 Good Driver (20%) $222.62 Distinguished $214.27 Driver Listed drivers on your policy _ ........ Ellen PO Ronald PO Jason PO Your Allstate agency is W Smith Ins Sery 1968 Lake Ave #101 Altadena CA 91001-3038 (626) 791-7636 WilbertSmith@allstate.com Some or all of the information on your Policy Declarations is used in the rating of your policy or it could affect your eligibility for certain coverages. Please notify us immediately if you believe that any information on your Policy Declarations is incorrect. We will make corrections once you have notified us, and any resulting rate adjustments, will be made only for the current policy period or for future policy periods. Please also notify us immediately if you believe any coverages are not listed or are inaccurately listed. Renewal auto policy declarations Policy number: 967 729 605 Policy effective date: November 8, 2022 Coverage detail for 2019 Honda Pilot Page 3 of 6 WAllstate. Coverage Limits � .........�.._.. —�_,_. Deductible _ Premium �. -.. ..._ Automobile Liability Insurance ble Not applicable $693.84 • Bodily Injury $100,000 each person $300,000 each occurrence • Property Damage $100,000 each occurrence Auto Collision Insurance Actual cash value $500 $608.52 Waiver of deductible applies _ Auto Comprehensive Insurance Actual cash value $500 $7318 Rental Reimbursement Not purchased* _ win and Labor Costs Tninsured Not -purchased . _W r Bodily$15 U Motorists Insurance fo � 000 each person p Not applicable�~ $52.36 Injury $30,000 each accident Automobile Medical Payments Not purchased* mm _.._. Coordinated Medical Protection Not purchased* System Sound Sy .._..._ w tem..........�..�- . Not purchased* �,.�.. w_... .... ....... _...... ......... Tape Not purchased* Total premium for 2019 Honda Pilot $1,427.90 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIN 5FNYF5H12KB010786 Lienholder Honda of Pasadena Rating information Your premium is determined based on certain information, including the Interested party following: Honda of Pasadena • This vehicle is driven 0-3 miles to work/school, unmarried person licensed 03 years. Allstate uses mileage information as one factor to help determine your premium amount. Important Note: The annual mileage figure applicable to this vehicle for the expiring policy period was: 2,500 - 2,999. The annual mileage figure applicable to this vehicle for the current policy period is: 7,000 - 7,499. The following odometer information was used to determine your annual mileage for current policy period: Odometer Reading:14,105 Odometer Reading: 21,417 Date: 07/19/2021 Date: 08/03/2022 If any of the information shown above is incorrect, missing or changes in the future, please contact your Allstate representative. Please keep in mind that a change in any of the information may result in an adjustment to your premium. 0 0 0 v 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: (_) 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 # d) 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 tho rovisions he agreement will automatically becor'ne void. Signature of Applicant Date 5/1/2024 Print Name Ronald Po Agreement for: Dated: Reviewed by: