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PROOF OF INSURANCE (2025 - 2025)CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 12/10/2024 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(s). PRODUCER CONTtCr' THIMBLE https://support.thimble.coml NAME; eri y Insurance Services, LLC D A Thimble Insurance Services PHONE rFAJt 174 West 4th Street, Suite 204 tAdG tlgx Fa;, A Na) E MAIL su on thimble.com New York, NY 10014 ADDR;_ https://support.thimble.com/ INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: INSURED INSURER B : Combine Academy 201 Standard Street, Apt 1, El Segundo, CA, 90245 „INSURER C djhoward0920@gmaii.com INSURER D ;. INSURER E : COVERAGES CERTIFICATE NUMBER: thimble.com/check-policy- 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. ....----- A.00.L .O.HH........ ......--- ...._,..__ ..... ,.POLICY EFF �POLJCYEXp "--- ...................... —INSURANCE i."PR TYPE OF INSURANCE 8 n POLICY NUMBER lMMIDDM/YY M OdYYY'y LIMITS X LIABILITY COMMMERCIERCI AL GENERAL-� 12/10/2024 12/10/2025 -EACH OCCURRENCE $ 1,000 000 -MADE X. occuR PM PM O S („Fe) $..... 10Q 00.�.. PST PST ' nPnR1,MISI n) $ 5,00 0 A -- � „ Y Y IBL-P3DM7SMQ3C E SONALA& ADV INJURY _._._.,� $ 1,000 000 IT APPLIES X N POLICAGGREGATE JPfi OC „PRODUOTSGCOMP OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE'. 9—MrT �..(E.—klegg. ...... ........... $ — ..... ANY AUTO BODILY INJURY (Per person) $ OWNED "-."..... SCHEDULED AUTOS ONLY AUTOS ......... .......-- accident) BODILY INJURY (Per cident)'.. ,. ---------- $ f HIRED NON -OWNED 0 ROPERrdDA/ AGE $ , ........ AUTOS ONLY AUTOS ONLY der -ecuadcsaq UMBRELLA LIAB OCCUR ( I EACH OCCURRENCE .... EXCLIARETEN I CLAIMS -MADE ,,,, ,AGGREGATE ,$ .. ............... DEDESS TION$ & $ WORKERS COMPENSATION TIER O I H- '.. AND EMPLOYERS' LIABILITY Y / N F ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ ....... . .... ....... ........ ....... ...................... ...... ---.....-.. (Mandatory in NH) E.L. DISEASE -_EA EMPLOYEE $ If yes, describe under ........ ---------------„ .... ..... ........ ..".... .. .......m DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ . ................................. _...,, ....._..................................µ ...� ........... ---` ',. $....... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) con't on form Acord 101 L;tK I IFIGA I E HULI t:K t;AN(;tLLA I ION The City of El Segundo, its officers, officials, employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE agents and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 n ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: Iho,?yardO920@gma-il.com LOC #: 1 ..... .......... A R "?" ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMEDINSURED Verifly Insurance Services, LLC DBA Thimble Insurance Services Combine Academy 201 Standard Street, Apt 1, El Segundo, CA, 90245 POLICY NUMBER djhoward0920@gmail.com IBL-P3DM7SMQ3C CARRIER NAIC CODE National Specialty Insurance Company 1 22608 1 EFFECTIVE DATE: ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserves. The ACORD name and logo are registered marks of ACORD THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL, INSURED This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. E-Mail Address: 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 above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance 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 LIM- ITS OF INSURANCE section of the coverage form 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; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 1 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission POLICY NUMBER: IBL-P3DM7SMQ3C COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. . WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): The City of El Segundo, its officers, officials, employees agents and volunteers 350 Main St. El Segundo, CA 90245 E-Mail Address: CombineContracting@gmail.com 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 above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance 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 LIM- ITS OF INSURANCE section of the coverage form 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; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 2 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: IBL-P3DM7SMQ3C COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVED OF TRANSFER OF FIGHTS ONE RECOVERY AGAINST OTHERS TO US (WAIVER OF SURE OGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): The City of El Segundo, its officers, officials, employees agents and volunteers 350 Main St. El Segundo, CA 90245 CombineContracting@gmail.com Information required to complete this Schedule, if not shown above, will be shown in the Declarations. V The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 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 Combine Academy. Date,j Z By. p Darrell George, City Ida ger For Roadside Assistance: 800-531-8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: usaa.com, . USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of'the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem. 6-13 50781-0513_ 02 ------------------------- -------- ----------------- ---------------- ----------------------------------- b -a c k-------------------------- CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25968 DAVID J HOWARD 25829 SEAGRASS TRL WILDOMAR CA 92595-7414 DAVID J HOWARD Insurance Company USAA CASUALTY INSURANCE COMPANY Policy Number Effective Date 02031 70 64C 7101 2 1 07/21 /24 California Evidence of Financial Responsibility Keep this card. IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of o financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, d impoundment or license suspension. Expiration Date Additional copies available at usaa.com 01 /21 /25 Vehicle Make/Vehicle Id .ntifir r Year VOLKS 2023 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 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: (_) 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_) 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 # WI 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 t h,agreement will automatically become void. ry - 12/10/2024 Signature of Applicant �'A, � Date Print Name David Howard Agreement for: Combine Contracting and Custodial Dated: •12/10/2024 Reviewed by: