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PROOF OF INSURANCE (2025 - 2025) CLOSEDCOVERAGES CERTIFICATE . ................................ . ................ _ . ....... ........................... NUMBER: A-SP-SU-24-04-12-302763 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. ........... . ............................. . .......................... OF IN&VRANCF . ADDL . SUBR .... . ...... ..... NUMKg_ . ..... POUCYEFF PO I UCYM ............... . . ................ . . ....... LIMITS.. ......................... ... GENERAL LIAEKLITY .QU.Qy EACHOCCURRENCE 0 100 A Y N BESGLPTNV01 1301 .. 170012.02 06111/2024 06/11/2025 11 1 I . " '0"00,.......... X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES 300,000.00 RENTED (Any one premises) ....... . . . rnisesj CLAIMS -MADE F_X] OCCUR MED EXP (any one person) $..5,000.00 .......... . ... . ... ....... .... X INCLUDES ATHLETIC PARTICIPANTS PERSONAL & ADV INJUR�_ _Q,Q00.00 . . . .......................... . . . 15_101-QQUIL . . ........ .... GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OGGREGAT P AGG ts 2,000,000.00 ------ - - - ------ . ...... -- — - -------- LO C $ AUTOMOBILE LABLrrY COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) $ ALL OWNED NON -OWNED AUTO F ...... ........ . . . . . . ....... . . . .........-- BODILY INJURY (Per person) $ AUTOS ----------- - - - - — - — - ------------ ............ ... ........... BODILY INJURY (Per accident) SCHEDULED� - PRO I P I EkW6X`1MA'-G—E— - ------- - ------- ------------------- ...... ,JAUTOS ........ . . . . . . . . . ............................. . . . .. . . . . . . . . . . . ....... . ...................... . . .. . ... . .......... ...... . ............ UMBRELLA LIAR OCCUR ACH OCCURRENCE E11 EXCESS LIAB CLAIMS MADE . I ......... - � ...... ..... . .. . . ............ . .. ........... . . . ........ I — ----- . .... . . . . . . . . . ......................... --- .. .. ... .. .. ... .. .. . . . . . ... ... ... ......................... . . . . ...... . .......... DEDUCTIBLE $ ........ .. . . i RETENTION $ ------------------ $ .. .. .. .. .. .. .. ........................... . . ...... . ....... --------- . . ..... WCSTATUI .. ANDEWPLOYERVIJABLITY NORY UMITS_� . ....... -E, ...................................... . . . . . . . . . . ........- ANY PROPRIETORPARTNEREXECI-MVE M OFFICERMEIVIBERExcLUDED9 W-xk*vyin*Q NIA E L EACH ACCIDENT $ If yes, describe under SPECIAL PROVISIONS below EL DISEASE - EA EMPLOYEE EL DISEASE -POLIEV.�LIMIT I1_ .. . .... ...... . ..... . OTHER ....... .................. A Abuse/Molestation Y N BESGLPTNV011301_17001202 06/11/2024 0611112025 Each Occurrence: $ 25,000 00 Aggregate: $ 50.000.00 DESCRIPTION OF OPERATIONS / 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 form CG 00 01 04 13 and company's specific forms Coverage for Participant Legal Liability requires that every participant signs a waiver/release. The certificate holder is named as Additional . ... .................. Insured with respect to (continued on next page) ................ CERTIFICATE HOLDER! CANCELLATION City of El Segundo. its officers, officials, employees, agents and volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 350 Main Street DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA, 90245 AUTHORIZED REPRESENTATIVE J, Mark Di Perno ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD @1988- 2009 ACORD CORPORATION. All rights reserved. .................. - AGENCY ... -. ---- ._.. NAMED INSURED Myers -Stevens & Toohey & Co., Inc. Champ Camp LLC .............��..........._.............................. - POLICY NUMBER ............��°°��___ _� �� _. ~^ 12655 Bluff Creek Drive #120 BESGLPTNV01 170012_02 Playa Vista, CARRI....,..,.,. ER ,.... J NAIC CODE � CA, 90094 Texas Insurance Company 16543 . DATE:TE: .06/1.1,,_..... .... EFFECTIVE/2024 ADDITIONAL REMARKS .,_._....................... .._...._.._.. .......... ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ©1988- 2009 ACORD CORPORATION. All rights reserved. POLICY NUMBER: BESGLPTNVO11201_170012_01 COMMERCIAL GENERAL LIABILITY CERTIFICATEM A-SP-SU-23-05-12-276834 CG 2011 04 13 NAMED INSURED: Champ Camp LLC POLICY PERIOD: June 11, 2023 to June 11, 2024 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Ref: Champ Camp LLC Name Of Person(s) Or Organization(s) (Additional Insured): Any person or organization if required by an insured contract provided such contract was executed prior to the occurrence or offense. City of El Segundo 350 Main Street El Segundo, CA, 90245 Additional Premium: $ Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. However: 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted by This endorsement shall not increase the law; and applicable Limits of Insurance shown in the Declarations. CG 2011 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 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 Champ Camp LLC. M:bl� �i -r., �10 �14, -.. M 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 Califomia one of the following declarations: U 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 § 37001 for the performance of the work set firth the agreement with the City of El Segundo. Policy. No. (_J 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 p ovis on ,or the agreement �will auto�matiautomatically become void. 7 Signature of Applicant Date Print Name Agreement for: ' `- Dated: Reviewed by: