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PROOF OF INSURANCE (2025 - 2025)SOCC-91 OP ID. ACORN' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11105'/2024 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 have ADDITIONAL INSURED provisions or 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(sj. PRODUCER RPS Bollinger Sports & Leisure PO Box 1322 Morristown, NJ 07960 David Campanello *Markel Insurance Com INSURED rAlnners Edge Sports Trehaing. t4054 North Lake Pleasant Park: 3eoria. AZ 85383 r1f%%1C0A1r_r-Q f1=0TICUTATC rd11AARIP-0• RFVISION NUMBER, THIS 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 INSURANCE iADDL�SUBRr..m. _ POLICY NUMBER............ ..i POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ,000 000 $ 1.... .- ........ LAIMS-ADE[X°OCCUR X s502AH01183D-4 11/05/2024 .... DAMAGE TO RENTED 11/05/2025 100 000 X In 1 Participants' AAIFD EXP (Myone p"arso„n) ._ 5 000 A......._ .... A X ,e al Abuse/Mol Sex 11MILL18zMILL 11/05/2024 11/05/2025 F ERSONAL.&ADV INJURY $ 1 000 000 �3 000,000 BENS LIMIT EkEATA' uM AGGREGATE C ENERALAGGREGATE $ ..... P LOC ..� �EG�G` ❑ ,PRODUCTS -COMP/OP AGG„ "",,,, 1,000 000 OTHER! COMBIPdD,_W.. dai.E LIMIT AUTOMOBILE LIABILITY klm� a;�J�la�ri. ANY AUTO ONLYINJq lFer,peMoO _$ _^ SCHEDULEDNED„„.-.--..., AUTOS ONLY AUTOS 1T )VRY P{,gr accident) $ PROPERTY W.., ..-......., HIRED NON -OWNED DAMAGE a••,'k.r,),&y $.... _,.,.. AUTOS ONLY AUTOS ONLY , - ... ...�.. .......... ... . q UMBRELLA LIAR........ OCCUR .... EXCESS LIAB CLAIMS MADE EACH OCCURRENCE ... ........ ........ DED RETENTION $ WORKERS COMPENSATION ( PER I J 5TATU_­ER.fH { AND EMPLOYERS' ILITY Y f N DENT $ ANY PERM EXOBLU R/ ECUTIVE I NIA E,L EACH ,ACC — ... " "....."".. MBER ato E, L ...... . LOYEE $ .,.,.,. .............. _ If yes, de TION under o DME. s, descHbe OF OPERATIONS below E L - P I Y LIMIT DIS SE A Accident Insurance 41OZAH025250-17 11 2024 /05/ 11/05/2025 Med Max: 25,000 Full Excess Ded: SS00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is included as an additional insured, Coverage is provided under these policies only for sponsored/supervised activities of the named insured for Which a premium has been paid. The City of El Segundo, its officers, officials, employees agents and volunteers 350 Main St El Segundo, CA 90245 ACORD 25 (2016/03) CITYELS 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 u� © 1988-2015 ACORD CORPORATION. All rights reserved. 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 Beginners Edge Sports Training LLC. Date: By. Darrell George, City Manager GEICO GEICO SECURE INSURANCE COMPANY To whom it may concern: This letter is to verify that we have issued coverage under the above policy number for the dates indicated in the effective and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle meets or exceeds the financial responsibility requirement for your state. This verification of coverage does not amend, extend or alter the coverage afforded by this policy. Vehicle Year: 2022 Make: BMW Model: X5 VIN: COVERAGES Bodily Injury Liability Each Person/Each Occurrence Property Damage Liability Medical Payments Uninsured Motorists Each Person/Each Occurrence Underinsured Motorist Each Person/Each Occurrence Comprehensive (Excluding Collision) Collision Emergency Road Service Rental Reimbursement Mechanical Breakdown X Lienholder LIMITS DEDUCTIBLES $100,000/$300,000 $100,000 $5,000 $100,000/$300,000 $100,000/$300,000 ERS FULL $50 Per Day / $1,500 Max Additional Insured Interested Party Additional Information: Issue Date: 12-30-24 $500 Ded $500 Ded $250 Ded U33 12-17 GlEICO GEICO SECURE INSURANCE COMPANY Washington DC VERIFICATION OF COVERAGE (SEE BELOW UNDER CAUTIONARY NOTE) If you have any additional questions, please call 1-800-841-3000. CAUTIONARY NOTE: THE CURRENT COVERAGES, LIMITS, AND DEDUCTIBLES MAY DIFFER FROM THE COVERAGES, LIMITS AND DEDUCTIBLES IN EFFECT AT OTHER TIMES DURING THE POLICY PERIOD. THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES, LIMITS, AND DEDUCTIBLES AS OF THE ISSUED DATE OF THIS DOCUMENT WHICH IS SHOWN UNDER "ADDITIONAL INFORMATION" OR IF AN ISSUED DATE IS NOT SHOWN, THE DATE OF THIS FACSIMILE OR EMAIL. U33 12-17 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. CX) 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 The Hartford Name of Agent Policy Number Expiration Date 76 WEG AZ6AML1 Phone # 714-874-4737 9/26/25 (_) 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 ttroose provisi or the a reement will automatically become void. r 8/31 /2024 Signature of Applicant Date Print Name Mitchell Goldberg Agreement for: Dated: Reviewed by: