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PROOF OF INSURANCE (2025 - 2026)AcoR� ......_.__... _ OF LIABILITY INSURANCE. ...... _ DATE /06/20 CERTIFICATE 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, thepolic Ies must be endorsed. If SUBROGATION IS WAIVED, subject - -- p y(� ) j 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). ...... ._ ... ... .............. ..------- ........ ... ... ._.....,., NAM,Y,. �. ...... .. ..�..... ....... ......... PRODUCER CONTACT The Camp Team, LLC PHONE FAX 800 747 9573 NPI 303 422 1276 ADDRESS: t)- Lrlfo�carT�p4e ......... ... 9035 Wadsworth Parkway, MAIL aIT% com PRiXiUER I .... _ ....... ... .... Suite 3820, 021 � c�� INSURED Sorts Marketing ......... (,) FFOROING COVERAGE NAIC # P CO Westminster, Program Management Accelerant Specialty Insurance Company 16890 --- City of El Segundo g g � INSURER B. ,...,�..„...___ . .. INSURER C: 350 Main Street w_..___ ... ... ..... INSUR..- El Segundo, CA, 90245 ER .........D ................... -- — ....... m �_ _.................... -... .......,.. ,, �w. INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: A-SP-SU-25_. -3 _NUMBER: _�. : ...�.........._........... _ 01 06-327552 �E1ilSIOf"t 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., _.................................. .... ...... ........_. ...................... ...w....e........_. SUBR .mL TYPE OF NSURANCE. „,„,...„,.. ... �. _ Y NUMBER P�EdT POLICY LIMITS.... EACH OCCURRENCE i OX ERALLWBCLITY RENTEDM(A1 - Opre-----_ $ 300,000.00 Op 000 00 - ......... A N N S0019GLoo0001-04 01/06I2025 01/06/2026 - es) COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [E OCCUR MED EXP (any one person) 4 $ 5,000 00 X V INJURY $1 000 000.00 %Nd".t.UL'YE:S ATHLETIC PARTICIPANTS PERSONAL B AD.....,,, GENERAL AGGREGATE is 3.000 000 00 GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $ 2,000,000 OO_ .., POLICY n PROJECT LOC AUTOMOBILE UABLITY COMBINED SINGLE LIMIT I ...J ANY AUTO HIRED AUTOS (Ea accident) RY ALL OWNED NON -OWNED BODILY INJUPer person)$ m. AUTOS AUTOS Ip PROPERI( 1. TY DAMAGE accident) „ „Y ............... SCHEDULED AUTOS _ Per arrident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE I$ ...,....�. .......... ... ..,.._. ...... EXCESS LIAB CLAIMS -MADE AGGREGATE �$ ....._ ._ WC STATU I H � ..... DEDUCTIBLE $ RETENTION $ I $ ADEMRJOYERSUA�IfY 1WORKERSOCIMPENSATION TORY.UAIITS...k...--- .L-..-.-- .,... ............... ------- ANY PROPRIETORPARTNEREXECIfTNE OFRCERMIENBER EXCLUDED? (Ma�yi wo N / A E.L. EACH ACCIDENT If yes, describe under � SPECIAL PROVISIONS below E,L, DISEASE - EA EMPLOYEE � E.L.: OISEASE-POLICYLI MIT S . .... ..................... ... . ........ ...... ...... ....... _..... ...................__.,... .... ..... ....... .... OTHER A Abuse/Molestation N N S0019GL000001-04 01/06/2025 01/06/2026 Each Occurrence:$ 100,000.00 Aggregate:$ 500,000.00 ......................... . m................. .._, ..._. ............._.. _„_... DESCRIPTION OF OPERATIONS / LOCATIONS I 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 —r —1, Mark Di Perno ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ©1988- 2009 ACORD CORPORATION. All rights reserved. 02008 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 Hollister Starrett. Date. B Y: Darrell George, City Manager --------------------------------------------------------------------------------------------------------------------- California Evidence of Liability Insurance VEHICLES ON POLICY Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I.D. # ' NAIL #: 15598 2005 TYTA PRIUS HYBRID 2021 TESL MODEL Y EV Named Insured Policy Number: CAA076908714 STARRETT w w DRIVERS ON POLICY C) STARRETT, HOLLISTER This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code. Coverage subject to policy terms and limits. 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. L_) 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 # (NI 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 04�12/24 Print Name Hollister Starrett Agreement for: Dated: Reviewed by: