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PROOF OF INSURANCE (2025 - 2026)Ac R CERTIFICATE OF LIABILITY INSURANCE ......................... °A0106120 5 5 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: .......................... ..... ._.................._. ... _..... __...,......... .m..._......... __ . .. .. .... If the certificate . to 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). �.µ .. ,. PRODUCER CONTACT ..................... __ ......... ............ ,._... .... .......m NAME' The Camp Team, LLC PHONE .. ... FAX 800 7479573 9035 Wadsworth Parkway, i s.µf ftl . 303 422 1276 t Ql�ri Suite 3820, acupR ss Info@campteenl,corn ........., .......... ...- PRODUCER Westminster, CO, 80021 cugfOMnkBD ................ - .... . INSURER(S�AFFORDING COVERAGE . .. ........ NAIC,# INSURED Sports Marketing Program Management Inc. INSURER A: Accelerant Specialty Insurance Company 16890 City of El Segundo - ... ... ..... INSURER B : ...... .. .... ... ... ........ .. ................ ... ....... 350 Main Street INSURER C : El Segundo, CA, 90245 INSURER D INSURER E :j�' INSURER F : -- Jm COVERAGES CERTIFICATE NUMBER: A-SP-SU-25-01-06-327552 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., INSR TYPE OF GhX URAN1qi% ADDL SUBR POLILYffF POLICYE1fP .... .... GENERAL LIABILITY EACH OCCURRENCE 1 aQQQ,000 00 A N N S0019GL000001-04 01/06/2025'01/06/2026 . X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES „ ,,,,,, X RENTED (Any one premises) $ 300,000.00 OCCUR MED EXP (any one person) $ 5 000.00, INCLUDES ATHLEDTICPARnCIPANITS . .. . -.... ,. X „PERSONAL & ADV INJURY ,$-1„,OOO.,,OOO..00_.......................................... GENERAL AGGREGATE $ 3,QQQ QQQ _QQ GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $ 2,000 000 00 X POLICY PROJECT LOC $ ....._ ..._......_ ...... _ ........ ......... _ _....................................................... ...- - ...- ......... ................................. ... ..... ........ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) S ALL OWNED NON -OWNED BODILY INJURY (Per person) $ AUTOS AUTOS (Per accldent) $ SCHEDULED _.T AUTOS Per ap,���� PROP INJURYRITYDAMAGE $ ,...__ ( pldent UMBRELLA LIAB OCCUR .EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ ..._..... _ ... DEDUCTIBLE $ ''.. RETENTION $ WOR1�77iSCONPENSATIW WC STATU ( OTH- LBY ....................................... . ANDS PLOYERSUTAB1 TOIl y,.,. T,S. ............... Eft....... .. ... . ANYPI140PRETOWaARTNEREXECUTIVE OFFICERIMENBFR EXCLUDED? (Madabyi W N / A E L, EACH ACCIDENT $ If yes, describe under SPECIAL PROVISIONS below................................................_._.�............... E.L. DISEASE - EA EMPLOYEE $ E..L DISEASE- POLICY LIMIT $ OTHER A Abuse/Molestation N N S0019GL000001-04 01/06/2025 01/06/2026 Each Occurrence:S 100,000.00 Aggregate:$ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Liability Policy Deductible: $0.00 Deductible for Bodily Injury and $ 1000,00 per Property Damage Claim., ISO Occurrence forth CG 00 01 04 13 and company's specific forms. Coverage for Participant Legal Liability requires that every participant signs a waiver/release, RE: Registered Drama participants: 01/06/2025 - 01/06/2026; CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA, 90245 Mark Di Perno ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ©1988- 2009 ACORD CORPORATION. All rights reserved. ©2008 ACORD CORPORATION. All rights reserved. ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD INSURANCE WAIVER Pursuant to Section 4 of El Segundo City Council Resolution No. 4813, the undersigned authorized the waiver of commercial auto insurance for the City of El Segundo instructor contract with Natalie Kahn. Date: i ZS BY: Darrell George, City Mana r Evidence of Insurance State of California Named Insured(s): Natalie Kahn Vehicle: 2017 Volkswagen New Jetta 4D 1.4TSE VIN: Registered Owner(s): Natalie Kahn This policy complies with Section 16056 of the California Vehicle Code KEEP THIS CERTIFICATE IN YOUR VEHICLE ATALLTIMES. Contact Farmers Claim Department or Roadside Assistance 24 hours a day at (800) 435-7764 Para Espanol, (lame al (877) 732-5266 FARMERS MSURANCE Policy Number:189959299 Effective: 10/23/2024 Expiration: 4/23/2025 ... KEEP WIT H VEHICLE NAIC Number: 21652 YourAgent:Solum Insurance Agency, Inc. 881 Alma Real Dr SteT30 Pacific Palisades, CA 90272-3776 Agent Phone: (310) 454-0805 Underwriting Company: Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills, CA91367 Phone: 1-888-327-6335 Report a claim at www.farmers.com, via the Farmers Mobile App or Contact your Farmers Agent At the scene of an accident: 1.Obtain the following: -- Name, address, and phone numberof each driver, passenger, and witness. Obtain a driver's license numberforeach driver. -- License plate number, insurance company, and policy numberof each involved vehicle. -- Photos of vehicle damage and accident scene. 2. Reportthe accident to the proper authorities. 3. Do not admitfault. An investigation may later reveal you were not responsible for the accident. 25-9011 8-19 Evidence of Insurance State of California Named Insured(s): Natalie Kahn Vehicle: 2017 Volkswagen New Jetta 4D 1.4T SE VIN: Registered Owner(s): Natalie Kahn This policy complies with Section 16056 of the California Vehicle Code INSURANCEE Policy Number: 189959299 Effective: 10/23/2024 Expiration: 4/23/2025 DMV REGISTRATION COPY NAIC Number: 21652 YourAgent:Solum Insurance Agency, Inc. 881 Alma Real Dr Ste T30 Pacific Palisades, CA 90272-3776 Agent Phone: (310) 454-0805 Underwriting Company: Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills, CA91367 Phone: 1-888-327-6335 The California Department of Motor Vehicles (DMV) requires proof of insurance when registering your vehicle. Please provide thisform to the DMV when registering your vehicle. 25-9011 8-19 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILUReTO 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. 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 Name of Agent Policy Number Expiration Date 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 Signature ly c li comply provisions or the agreement will automatically become void. immediate) com I with those g y pp P Y°1�,�1"�� Date 12/15/24 Print Name Natalie Kahn Agreement for: Dated: Reviewed by: