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PROOF OF INSURANCE (2025 - 2026).....,. �. .,. ......... DATE (MMIDDIYYYY) .. .. C"R CERTIFICATE OF LIABILITY INSURANCE 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). 3 .. PRODUCER CONTACT The Camp Team, LLC PHONE irlfo CafUk ie FAX 303 800 747 957 422 1276 9035 Wadsworth Parkway, 6-MAIL _ ( "?s'a). Suite 3620, ADDRESS _..._ p .am COT1 Westminster, CO, 80021 4lIxSMM!,tTt16?_a.. ........................ .... ,_ ., ..,...,... ........ __....... ........._._._. .. ..___.INSLIUR.LS,)_AFFORDING COVERAGE..... NAIC,# INSURED Sports Marketing Program Management Inc. _ p Company City of El Segundo 6890 INSURERA Accelerants ecial InsuranceComan 1 INSURER B : INSURER C : 350 Main Street ---- El Segundo, CA, 90245 INSURER D INSURER E .....___ ....... ......... _ .. ...............I INSURER F COVERAGES CERTIFICATE NUMBER: A-SP-SU-25-01-06-327552 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. ..._._.._.. ... .,I_STYPE IF INSURANCES ADOL SUSR POULYEFF POLICYEXP INR �. ..— NS&.. VD.._. LIMITS GENERAL LIABILITY E CH A COMMERCIAL GENERAL LIABILITY N N S0019GL000001-04 01/06/2025 01/06/2026 FIRE DAMAGE TO O PREMISES ..l�"1',000 00QA0 _... 4 y $ person) 5 000 00 X CLAIMS -MADE OCCUR $ 300 X� MED EP an one 000 00 X INCLUDES ATHLETIC PARTICIPANTS PERSONAL 8 ADV INJURY $ 1,000 000.00 GENERAL AGGREGATE 3,00.0,00000 GENERAL AGGREGATE PLIMIT APPLIES PER: LOC tl '"........................................PRODUCTS COMP/OP AGG $ 2L000r000 0,0 POL p.:__.., ... .... ... ..... ...... .,..... ... ....,..._......�... _................... _.._.... ...� AUTOMOBILE LIABILITY ............. „„„„„„„, COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) "a BODILY INJURY D eracciden[) �$ '..... AUTOS AUTOS BODILY INJURY (per person) ALL OWNENON-OWNED .., ............................... ... PROPE ----------- .,. ..... GE SCHEDULED AUTOS (Per accident„j, $ UMBRELLA LIAB rCCUR EACH OCCURRENCE $ EXCESS ..... .0 ... ....... .LIAB LAIMS-MADE AGGREGATE $ DEDUCTIBLE....... $ __...,_ RETENTION. $_.............. $ WORIERSCOMPHJS4110N WCSTATU- O`TH- ADEPLOYERSWIBlgY TORY.LlMITS. s ER ........, .. ANY PROPRIEfORPARTNERIDIECUTNE OFFICE}ZMEMBER EXCLUDED? Fand*xyn*Q NIA''. E,L, EACH ACCIDENT 5 If yes, describe under SPECIAL PROVISIONS below E.L.. DISEASE- EA EMPLOYEE $ _... E.L. DISEASE- POLICY LIMIT $ 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 / 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. RE: Registered Drama participants: 01/06/2025 - 01106/2026; .................................................... ........... ......... 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. ©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 Krystyna Rodriguez. Date:" 2 By: Darrell George, City Manager PROGRESSIVE P.O. BOX 31260 TAMPA, FL 33631 NAIC Company Code: 11770 "Verification of Insurance for Krystyna Rodriguez D/RECT Auto Policy Number: 979903212 Underwritten by: United Financial Cas Co Policyholder: Krystyna Rodriguez Page 1 of 1 January 5, 2025 Customer Service 1-800-776-4737 24 hours a day, 7 days a week This verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of the policies. Please accept this letter as verification of insurance for this policy, Policy and driver information Poli,...number�....., ,�.��.... .....��... ................ ry �..,.,.. ...... �.. 979903212 Policy state: ....................................................................................... ryCalifornia ........................................................................ Policyperiod: p . . Oct 26, 2024-............ .... �� �� Apr 26, 2025 ... .................... ... .. ... .................................................................... There was no lapse in average during this policy period, ........... _ ................ .. ...... . Effective date: ............. ........... Oct 26, 2024 ........................................... ....... ....,.. ....... Drivers° Krystyna...... Rodriguez ............................................................................................................. ...................................... Address: Vehicle information Vehicle: 2015 MITSUBISHI OUTLANDER .. _...... . ...... Vehicle identification number: Coverage information ............................................. . Liability To Others Bodily Injury Liability $15,000 each person/$30,000 each accident Property Damage Liability $5,000 each accident MIZZIUMN 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 perjuryunder the laws of Califomia 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. (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 Name of Agent Policy Number Expiration Date Phone # (>Q 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 '11 licant imgmediately comply ply with those provisions or the a reement will automatically ecome void. Date I1.24 Sinature of A �J Print Name " Agreement for Srystyna Rodriguez Dated- 04.11.24 Reviewed t}y: r y