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PROOF OF INSURANCE (2024 - 2024)44C��^- pp��qq���1r•^�, DATE (MMIDD/YYYY) 'L..+rpl^et.. .. CERTIFICATE OF LIABILITY INSURANCE 10/04/2024 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 The Camp Team 9035 WADSWORTH PKWY STE 3820 WESTMINSTER, CO 80021-4541 CONTACT NAME: A C, No. Ex r HONE FAX No ; (303) 422-1276 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # ''... INSURERA: Great American Insurance Company 16691 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ''..... INSURERB : ITS PARTICIPATING MEMBERS: INsuRERc: City Of El Segundo 640 MAIN ST INSURERD: EL SEGUNDO, CA 90245 INSURERE: INSURERF: COVERAGES CERTIFICATE. NUMBER: GAS153627 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. ub R AOUL ti'7J R LTR TYPE OF INSURANCE INSR bWVD POLICY EFF POLICY EXP POLICY NUMBER MMIDD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $300,000PREPAISES X COMMERCIAL GENERAL LIABILITY Ea rrrurrence} CLAIMS -MADE OCCUR MED EXP (Any one person) $10,000 1..:.LJ PAC 4725036 10/26/2024 10/27/2024 PERSONAL & ADV INJURY $1,000,000 A X HOST LIQUOR LIABILITY INCLUDED 12:00 AM 12:01 AM GENERAL AGGREGATE $1,000,000 '... GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP/OP AGG $1,000,000 X '.,, POLICY P.RO LOC ' COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY '... Ea arridwl ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY itPor AUTOS AUTOS ar<C6MJePdI` NON -OWNED PROPERTY"DAMAGE HIREDAUTO AUTOS f Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LU1B Id CLAIMS -MADE AGGREGATE DED RETENTION $ 10/26/2024 10/27/2024 EACH OCCURRENCE $1,000,000 A Professional Liability PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Covered Activities: Panel Discussion/Q & A Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATE HOLDER CANCELLATION Proof of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Tl,& Ca.wl ry Tea411 ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER CAAP0000834390 YEARJMAKEIMODEL 2023 MERCEDES EQS 450t NAMED INSURED U 0 E L L ADDITIONAL DRIVER(S) Owen Kugell CALIFORNIA EVIDENCE OF LIABILITY INSURANCE Mercury Insurance Company P.O. Box 10730 Santa Ana CA 92711-0730 AGENCY: WORTHINGTON INSURANCE SERVICES 562-795-5744 EFFECTIVE I EXPIRATION DATES 06/09/2024 12/0912024 VEHICLE IDENTIFICATION NUMBER TO REPORT A CLAIM, please call(800) 503-3724. For access to ROADSIDE ASSISTANCE ONLY, please call (866) 519-6478. This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code Evidence of financial responsibility shall at all times be carried in the vehicle. Insurance information has already been submitted to the DMV electronically, submit this document to DMV only if specifically requested by DMV. CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES DOLLARS 100 0 00 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DO ($ ), 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 # 4-1 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 bec e subject tp the workers' compensation provisions of Labor Code § 3700 1 must immediately comply a with tl s profs n or a? n't will automatically become void. Sig p Date Print Name s '�''C�-'le" Agreement for: -Al WO T— k )L L- Dated: 7 1P Reviewed by:a,/p,A- 10 epq-