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PROOF OF INSURANCE (2024 - 2025)CERTIFICATE OF LIAI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY At CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EJ BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE i REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE. HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pc to the terms and conditions of the policy, certain policies may require an e to the certificate holder in lieu of such endorsement s PRODUCER The Camp Team 9035 WADSWORTH PKWY STE 3820 WESTMINSTER, CO 80021-4541 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ITS PARTICIPATING MEMBERS: City Of El Segundo 640 MAIN ST EL SEGUNDO, CA 90245 fDATEMIDD/YYYY) 31LITY INSURANCE 04/2024 ID CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS (TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 4 CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED licy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject Indorsement. A statement on this certificate does not confer rights CONTACT NAME: FAx PHONE (303) 422-1276 AIC No Ex!: A8C No E-MAIL ADDRE.SS! INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Company 16691 '.. INSURER B INSURER C t INSURER D t INSURER E ; INSURER F ; 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. INS. ADDL SUblK LTR TYPE OF INSURANCE INSR WYVCs POLICY EF'F PDLBG"1' ETI;P LIMITS POLICY NUMBER Mmm"YYY N414t QDNYYY... -. EACH OCCURRENCE $1,000,000 GENERAL LIABILITY -- --- 00, �AhM�IAC+f TCb Nta:.rr�� $300,000 '... +fir COMMERCIAL GENERAL LIABILITY iT'� CRkl9ir+,�" �'gp co-rwnN�iea,n�� o MED EXP (Any one person) $10,000 GLAIMS-MADE X OCCUR A Xi. HOST LIQUOR LIABILITY INCLUDED 10/ 26/2024 10/27/2024 PAC 4725036 12:00 AM 12:01 AM PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $1,000,000 PRODUCTS -COMP/OP AGG $1,000,000 DEVILAGGREGATELIMIT APPLIES PER: PRQ- X POLICY '�,E,C�- LGG C4'TM MINED SINGLE H.YIMNti`... AUTOMOBILE LIABILITY Era SnTl;oe"t '... BODILY INJURY (Per person) ANY AUTO BODH.Y INJURY (Per ALL OWNED SCHEDULED 3CCa�lont. AUTOS AUTOS RROPE�Y�'TY DAMAFE NON -OWNED HIRED AUTO AUTOS d^a'a� m4CV+4urri EACH OCCURRENCE UMBRELLA LIAB occuR AGGREGATE EXCESS LIAB GLAIMS-MADE DEO RETENTION $ PAProfessional 10/26/2024 10/27/2024 EACH OCCURRENCE $1,000,000 Liability PACs 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if morespace 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 Tkt, Cawfy -ruw, ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD %("a"'ALIFORNIA st*Arm NSURANC CARD'' r,l1�F�llfG6�UJ�l�r .r,,,.)N)I� G ti'�" N ir�rd9rffay u�aUUJJw)�/ unlumiii�eP� State Farm Mutual Autom obile Insurance Company ✓ j PO x 2358 El�i�r ton IL 61702-2358 �' INSURED wILT+��a HEII Y vo L d POLICY NUMBER L21 8162-A08-75L EFFECTIVE � YR 2021 - -MAKE TOYOTA JUL 08 2024, TO JAN 062025 MODEL PRIUS VI AGENT DANIEL WILLIAMS INS AGENCY INC 8193-0014 PHONE (123 852-6868 NAIL '25178 COVERAG PR VI0ED BY THE POLICY MEETS THE MINIMUM LIAB11,11 'Y LIMff,,S PRESCRIBED BY LAVA. COVERAGES A D500 G500 RI U U1 SEE REVERSE SIDE FOR AN EXPLANATION. 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 o gent 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 § 3700 1 must immediately comply with those provisions or the pDrVTent will automatically become void. Signature of Applicant Print Name Agreement for: VPZ, I LT Dated: 9 . 6 yq Reviewed by: om