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PROOF OF INSURANCE (2025) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD,YYYY,
08/19/2024
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 endorsements .
PRODUCER CONTACT
The 9035 amp Tea RTH PKWY STE 3820 gH�(800) 747 9573 � A/C No_
PHOWAD
NE
FAX (303)422-1276
WESTMINSTER, CO 80021-4541 E-MAIL
nnntal"•q— jstevens ..campteam,com
INSURERA:
..., ..... .......,. ...... _...... . ......... _.._
INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B :
ITS PARTICIPATING MEMBERS: """
City of El Segundo ....RC
350 MAIN ST INSURERD:
EL SEGUNDO, CA 90245-3895 INSURERE:
INSURER F
INSURER(S) AFFORDING COVERAGE NAIC #
...._ ................
Great. ._...
American Insurance Company 16691
____ ____ ..-...�.�....��... .....�.._ i+wn�rn�oo DC\/ICIr\AI 1V11MRFR•
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.
EXP
INIS TYPE OF INSURANCE SUBR POLICYNUMBER RPAdO1p yCYEYYE11 pPOLpgy YYY
LTR INSR NSR 11ND
LT
LIMITS
EACH OCCURRENCE
11,000,000
GENERAL LIABILITY
'
....
DaMaGE Y�J FCCAl1a LT
$300,000
X COMMERCIAL GENERAL LIABILITY
I'RI;,MpSE,"",{Eyrw�rrrnerr'
CLAIMS -MADE OCCUR
MED EXP (Any one person)
$10,000
08/14/2024
01/01/2025
A
X HOST LIQUOR LIABILITY INCLUDED
PAC 4725036
12:00 AM
12:01 AM
PERSONAL & AD INJURY
PERSONAL
$1,000,000
... _-.......... .._.._.._...,
GENERAL AGGREGATE
$1,000,000
.. ......._...
GEN L AGGREGATE LIMIT APPLIES PER:
......,
PRODUCTS-COMP/OP AGG
.........m...m.. ..
$1,000,000
...
R-
X . PPOLICY JE&O:"- LOS
SONIMNED SINGLE ILII«rA1"
AUTOMOBILE LIABILITY
„ JAR!w,,,;e dw o .
... ....
ANY AUTO
BODILY INJURY(Per person)
ALL OWNED SCHEDULED
AUTOS
BODILY MJURY
ACClday:[Y1
.,,.
AUTOS
'... NON -OWNED
_......................
PROPERTY DAMAGE
.....„
HIRED AUTO AUTOS
nor rndmnq ITIT-....-
......�...'."
'.. UMBRELLA LIAB OCCUR
CE EACH OCCURREN
,.....
EXCESS LIAB CLAIMS -MADE
AGGREGATE
DED RETENTION $
08/14/2024
01/01/2025
EACH OCCURRENCE
$1,000,000
A
Professional Liability
PAC 4725036
12:00 AM
12:01 AM
AGGREGATE LIMIT
$1,000,000
08/14/2024
01/01/2025
EACH OCCURRENCE
$100,000
A
Abuse and Molestation
PAC 4725036
12:00 AM
12:01 AM
GENERAL AGGREGATE
$300,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Covered Activities: Board Games, Live Music Events
Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage
rcDTIorATo unl nGD CANCELLATION
Proof of Insurance
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
TPL,P, Ca4 y Te a vw
ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
CITY OF a SF-GUNPC
WORKERS' COMPENSATION ON OLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
I$ UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL NAL PENALTIES
AND CIVIL PLANES UP" TO ONE HUNDRED THOUSAND DOLLARS (`' ,000),
IN ADDITION TO THE COST OF -COMPENSATION, DAMAGES AS ;NPR WDED
FOR AN 1ABOR,CODE § 3706, INTEREST, AND ATTOR N.E'Y'S -FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations;
U l h4va awl wllN 1*014111 qodifimoaf p1 1s Cif f elf .lrl lr for wp6pfs' 1ppnsgjipn, tssgpct y Nhe I I( of r
of Industrial Relations as provided for by tabor Code § 3700 for the perfOrmanoe of the work set forth the agreement
with the City of El Segundo.
Poffoy No
L j} I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
of the worts for which the agreement with the City of El Segundo is executed, My workers' compensation insurance
.carderoiid poIIrcy ritlMmr-Arid_
Carrier
Nania of Agent
Policy Number Expiratlon Date
Phone #
j 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 tas his warkwo' aKiMPansa[fa n praAllaris Of Wtxr Cade 9 3700 i must
Immediately comply with those provlsl ns or the agreement will automatically become void.
Signature al'A lZlicant t Date
Print Dame AX411 PjakW
Agreement for -
Dated: -711- �11,-;'02'
Reviewed b � " / fi alvfe-ly