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PROOF OF INSURANCE (2025 - 2026) CLOSED�L' CERTIFICATE OF LIABILITY INSURANCE A�RO" DATE(MMID0"YYY, � 01I06I2025 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 �.coNrac NAME,, The Camp Team, LLC PHONE FAX 800 747-9573 303-422-1276 9035 Wadsworth Parkway, 10vG No' )EAL ,AK, Ng,. `E ADOREss infoQcampteam.com Suite 3820, �... PROMx3m Westminster, CO, 80021.Q_L .......... .m.m........................ i .m INSURER(S),AFFORDING COVERAGE NAIC M INSURED Sports Marketing Program Management Inc. INSURER A Accelerant Specialty Insurance Company 16890 City of El Segundo INSURER B ......._ ....... ...... INSURER C 350 Main Street El Segundo, CA, 90245 INSURER D INSURER E : ............. ............ ............. ............. ............. ....,........ ..... ................................... ...... ............................................................................................................................................................................................................................................................................. __...................................................................................................................................................................................................................................................................................................,........................................................................................... INSURER F ' COVERAGES CERTIFICATE NUMBER: A SP-SU-25-01-06-327552 REVISION NUMBER: THIS IS'TO CERTIFY THAT THE POLICIES OF INSURANCE lUSTF.D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOrwrrHSTANDING ANY REQUIREMENT, TERM OR CONDPION 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 HEREON IS SUBJECT TO ALL TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR �... POLICY i3F ----- {IILYFJ� ___ ____ LIMITS d .......... TYPE OF INSURANCE GENERALLIABILITY ,1;�SB., U+.S,11wl.m.ofwlt,._ �JMIIKICII__ _____`____ E 0 A N N S0019GL000001-04 01I06I2025 01I06I2026 ,EACH"OCCURRE " �5,_,�l X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES P 00,0," 0 RENTED (Any one remises) MED P (any one person] i$ 5 0, � INCLUDES ATHLETIC PARTICIPANTS NAL a ADv INJURY PERSONAL $1 000 000.00 ...... .......... GENERAL AGGREGATE ...... ..,,:,, � $ 3�OQO,000.OQ, -.,_ GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2ryQ000,r00QQ „ �� POLICY ES PROJECT ( LOG $ w...,,., AUTOMOBILE 11ABllfY -------- -------------- -- — ----------- COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO HIRED AUTOS ED D ILY I N JURY,( Per person) ALL OWNED NON -OWNED 11 11 I I AUTOS AUTOS BODILY INJURY (Per accident) $ $ SCHEDULED AUTOS , (Per,acaden0,- ... ... .. ,.., ..a -.. W,A.�.wa.,..w._...... .._ .._�_ ,.,.,.,.,.,. _ ... .... ......... _......M...-... .. .. ,�,�, v„v ...... UMBRELlJ1 LIAR OCCUR EACH OCCURRENCE $ .�......,---- ___------ EXCESS LIAB .mm CLAIMS MADE AGGREGATE $ .._ .... DEDUCTIBLE $ , RETENTION $..... $ WaR143Sr�B�64TICN ......... ......... ......... WC STATU ....... tST H- II II f ..... AND 9Yfl1T'6Sl1ABllfY TSJHLdh1dT l .1. .JwR3_,........ .�eeeeeeeeeeeeeeeeeeeee. ����. ANY PROPRIETORIPARTNERtEXECUTWE E)(C (Msd�ryinfJQ NIA . F _A H ACCIDENT E If yes, describe under SPECIAL PROVISIONS below L.. DISEASEEMPt.OYF ...................� E' IS .E I$ E L. DISEASE - POLICY LIM1AIT I S OTHER- __.._________...................................._................................... A Abuse/Molestation N 'N S0019GL000001-04 01/06/2025 01/06/2026 Each Occurrence: $100,000 00 Aggregate:$ 500,000.00 ................................................................................................................................... ''. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, Of more space is required) Liability Policy Deductible: $0.00 Deductible for Bodily Injury and $ 1000.00 per Property Damage Claim. ISO Occurrenceform COG 00 01 04 13 and company's specificformsCoverage for Participant Legal Liability requires that every participant signs a waiver/release. RE: Registered Drama participants: 01/06/2025 - 01/06/2026; City of El Segundo 350 Main Street El Segundo, CA, 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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 Jenna Lockwood. Date: — I Al� sy: D rrelI George, City Manager 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: L) 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. C-V) 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 # 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 agreement will automatically become void. Signature of Applicant & Date--12/6/23 Print Name Agreement for: Dated: 12105Z23 Reviewed by: