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PROOF OF INSURANCE (2025 - 2025) CLOSEDCERTIFICATE OF LIABILITY INSURANCE12/16/DATE(M/2024 Y) 024 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 CONTACT The Camp Team NAMrEtl: FAY. (V16691 9035 WADSWORTH PKWY STE 3820 AtC, No Etta : AIC, No : E-MAIL ADDRESS: WESTMINSTER, CO 80021-4541 INSURER(S) AFFORDING COVERAGE INSURERA: Great American Insurance Company INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER ; ITS PARTICIPATING MEMBERS: INSURER I City Of El Segundo 650 MAIN ST INSURERD: EL SEGUNDO, CA 90245 INSURER E r INSURERF: COVERAGES CERTIFICATE NUMBER: GAS156609 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, EX'CLUISIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE, BEEN REDUCED BY PAID CLAIMS, LT R TYPE OF INSURANCE ADDL VOVD L,TR ANSR. NPdVD POLICY NUMBER POLICY EFF POL�Cvmmof F.X�Rr LIMITS 'MMr4/007'A°Y'Y'Y 'dr,MMld'bC)R"a''YY'V'. EACH OCCURRENCE $1,000,000 GENERAL LIABILITY pm'AGE'G .""TE D. $300,000 X COMMERCIAL GENERAL LIABILITY PRT"MJIS'E & � MED EXP (Ann oneperson) $1 0,000 CLAIMS -MADE OCCUR - PERSONAL INJURYRY 4725036 01/18/2025 01/19/2025 00,000 A X ''.. HOST LIQUOR LIABILITY INCLUDED PAC 12:00 AM 12:01 AM GENERAL AGGREGATE $1,000,000 '.. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1,000,000 PRO X POLICY �1k'"CiI LOC (7QPM%Y1NSD 51&�4a"7E1.FHT AUTOMOBILE LIABILITY (Ew accatlew) ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY Wer AUTOS AUTOS r'k�`kaadont�. NON -OWNED �w JAhWAO drGC HIRED AUTO AUTOS EACH OCCURRENCE UMBRELLA LIAB OCCUR EXCESS LIAR Id CLAIMS MADE AGGREGATE. I:dEED RETENTION $ 01/18/2025 01/19/2025 EACH OCCURRENCE $1,000,000 A Professional Liability PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covered Activities: Musical Performance 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 &-r" Tecww ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 11\�,° ����o��� 1 ��� 1.......... .nano ;� Keep these cards handy --in your glove compartment or wallet. And contact us anytime you have a question or need to report a claim. If you have a claim, we'll get you back on the road as soon as possible. And while you'll always have a choice where to repair your vehicle, when you use a shop in our preapproved network, we'll guarantee your repair for as long as you own or lease your vehicle. Thank you for choosing Progressive. °T Yuki Shibamoto [ I I Valued Customer Since 2023 I I f I C I I I' I I Form A022 (10/20) i IF YOU'RE IN AN ACCIDENT i 1. Remain at the scene. Dont admit fault. I; 2. Find a safe location, call the police, and exchange driver information. i 3. Call Progressive right away. II TO REPORT A CLAIM Call 1-800-274-4499 or go to claims.progressive.com. KEEP THIS CARD IN YOUR VEHICLE WHILE IN OPERATION. INSURANCE IDENTIFICATION CARD - California Policy Number: 966470002 NAIC Number: 10192 Effective Date: 08/20/2024 Expiration Date: 02/20/2025 Insurer: Progressive Select Ins Co 1-800-776-4737 PO Box 31260 Tampa, FL 33631 Named Insured(s): Yuki Shibamoto Year Make Model VIN 2016 Toyota Prius V Your policy meets the requirements of Section 16056. V a n 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 # 1) 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 become subject to the workers' compensation provisions of Labor Code § 3700 1 must Signature ly comply Applicant p agreement will automatically become void, �, � 12/ 10/2024 immediately c PP I with those provisions or the a re �� Date Print Name Yuki Shibaffi fo Agreement for: Yuki Shibamoto Dated: 12/ 10/2024. Reviewed by: