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PROOF OF INSURANCE (2025 - 2026)CERTIFICATE OF LIABILITY DATE `' .........�...... INSURANCE I \ C E E (MMIDDIYYYY) _ ... ........- I N.S ...................... _ ............ . 01106I2025 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 tot e 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 CONTACT NALAE "" The Camp Team, LLC PHONE FAX 800 747 9573 r 303422 1276 9035 Wadsworth Parkway,tAIL4.'a0, "C.Naf Suite 3820, ¢rDfrEss;. info campteam.com A PRODUCER Westminster, CO, 80021 CkA$TO.OWt1 _ . INSURERS) AFFORDING COVERAGE _ """"" "NAIC # INSURED ...-,.,,,,_._ .. ,......... en ,,"e............... ........_.____ ----- .. .��...... ......... INSURER..A .......... "- p ...ltyy -- ..�...1 INSURED Sorts Marketing Program Management Inc.890 City Of El Segundo INSURER A Accelerant Specialty Insurance CoCom an 1 INSURERC .. ... .. 350 Main Street -. ....... ... ....._. .. INSURER D El Segundo, CA, 90245 INSURER E .. ...............,. -- ..__. J INSURER F ` COVERAGES CERTIFICATE NUMBER; A-SP-SU-25- _.,. ..... __._...._................. _. °-�01-06-27m2 ....._REVISION NUMBR.........� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ............_..�.._. �n..,— _...�..,. - .................. ._.m... .. ........_ POUCYEXP ... LIMITS INSR GENERAL LIABILITY �� ..__. _• .. TYPE F INSURANCE ..YxA�J3:��., ..L'�p IU.Y N4DMBE$,,,,,,,,,,,,,,_,,,,,,,,,,,,,,._„ „. A N N S0019GL000001-04 01/06/2025 01/06/2026 RENTED OCCURRENCE $,1 y000i000 0p, X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE one PREMISES $ 300,000.00 CLAIMS -MADE OCCUR VIED EXP ......... ... ----- V —.-..p_,.__.._) ..... _� ,. X INCLUDES ATHLETIC PCIPANTS PERSONAL & ADV INJURY ny one person) f $ 1 OOO OOO, OO ....... �,3 000 000 00". GREGATE GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTS G.COMP.O"P AGG . $ 2 ...000.0OO O0 .,, POLICY PROJECT LOC is AUTOMOBILE L X ....... ........ ....... ITITITITITITIT COMBINED SINGLE LIMIT (Ea accident) $ r ( ANY AUTO HIRED AUTOS .�.� ........._. ......... L ......... _......-~. . _ H BODLLYLNJURY Per ) I$AUTOS AUTOS••ALL OWNEDNON-OWNED BODILY INJURY (Per accperson- ident) �---- ......... $ PROPE RTYDAMAGE $ SCHEDULED AUTOS (Per ecc)dentln„ ,,,, UMBRELLA LIAR OCCUR EACH OCCURRENCE ..........___ ........ ... EXCESS LU18 CLAIMS -MADE AGGREGATE $ „ DEDUCTIBLE $ RETENTION $ $ - WC STATU �ff - ENPLOYERS'LIABL1rY .� rD&Y LIMIIS_ I ..1_E.R,...... _..------- _. ---------- _...._. ANY PROPRIETORPARTNERID(ECUTIVE OFFICERMIEMBEREXCLUDED? M E L. EACH ACCIDENT $ (Ma dlorynN I N I A If yes, describe under SPECIAL PROVISIONS below E.L DISE ASE EMPLOYEE $ E,.L. DISEASE - POLICY LIMIT �.... .................. ..... ........ . ........... ................_ ww. .. _.,. 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 / 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 forth CG 00 01 04 13 and company's specific forms. Coverage for Participant Legal Liability requires that every participant signs a waivertrelease. RE: Registered Drama participants: 01/06/2025 - 01/06/2026: .W._._................. . . ............. ...................... ................... ................................... 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 __JQ , / e - , 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 (2008101) 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 MycKinnon Forsyth Date: B: _ �O Darrell George, City Manager INIpOKIAN F01 D Tor &NDROTY0M oUYARD ON pvpFOR A I It)" `11`0 14 N I A Fqtjyj Mutual Aulowoobile I,,%%ranre Company ionlL$1702-2350 MI?' ADXI R-1, YVIC14 TC RRIN VOL EFFECTIVE POLICY NUMBER wq 0210-r 29-7t5C EC 29 2024 T & JUN 29 2025 ylw 2, ,D16 MAXE VOLKSWAGEN—g—k- — ktDjj GOLF OIMN$ — :--r— - -,%75 _N jt4C SRAND,014 FOSTER AGEN NC FA51'7r, '31PeNIMC 26178 UM LIABILITY LIMITS 22-5840 PR BY 1,14r.. potjry tAEFTS, THE MINIM Uv, "9E gF0W05E' u 1 $ F SIDE FOR AN OWLANATION SUBMIT THIS CARD, OR PHOTOCOPY Or KEEP YOUR CURRENT CARD UNTIL THE" 0 I C2003 40� 1d 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: C_) 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. (_) 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 # (-X 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 Signature of Applicant void. immediate) comply with thos rovisi s or the agreement will automatically become rl� 111h Y PY P 9 Y 9Date Print Name `d" Cf I riVI 1 f 1+11A Agreement for: Dated: Reviewed by: