Loading...
PROOF OF INSURANCE (2025 - 2026)� INSURANCE U RA.. Dam �..� ... ...._ w..IABILITY .NCE TE(MMIDDIYYYY) 01I06I2025 r CERTIFICATEOFL....... I'll, -- ....._. THIS CERTIFICATE IS ISSUED AS A ON 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 - T 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). . ... ....,w......, __..... ............. ....... -- ----._._ PRODUCER NAME The Cam Team, LLC PHONE P t Np EXfl 800 747 9573 d-G.N _ 303-422 1276 9035 Wadsworth Parkway, EPNAIL am Com ADDRESS infO Q Oample .. .. Suite 3820, i4idbu ER Westminster, CO, 800210I13 -.INSURED 5 orts......URER... (.)..ialt. ......_ _ NAIC g ...___ .. .......... ... ..... _.____l Specialty COVERAGP..y ...L........w ..._ nt Inc.lnc. INSURER..... .. .... .......... .... 6890 ... __. City of El Segundo INSURER P 9 9 e Accelerant S eaal Insurance Company 1 ro ram Mana eme �, I INSURER C INSURER 350 Main Street — El Segundo, CA, 90245 D INSURER E INSURER.. ......._,. .... ., ,,".,. ..--- ................ ..... ..,......_,_.. F .....,_.......................�..........,...._,_.,.._. COVERAGES � CERTIFICATE DUMBER: 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, ,.........._.. ...._......... _�........... _..... .... ,LIMITS ....�..... INSR TVPE OF IN59RANCE 1NL"C1 "" ..._. 50019GL00000 t ,....... I ......... POLICY NUi1tN _ . .... ...�. ,,... .. EACH OCCURRENCE A N IN04 01I06/2025 01I06/2026 Q 000 00„ X COMMERCIAL GENERAL LIABILITY RENTED An one PREMISES $ 300,000.00 -------- GENERAL LNAB6LGrY FIRE DAMAGE TO PREMISES premises)$ 1 QQ,........... CLAIMS-M - 1...." Person) $ 5 QQQ.00 .. ,..... XP (any one .......... _ .a ....,. X OCCUR X PERSONAL & ADV INJURY $ 1,000,000.00 ah CLU09-S ATHAETIC PARTICIPANTS �„ DE EGATE 3 QpQ 000 00"" GENERAL AGGREGATE LIMIT APPLIES PER: PRODUCTSGCOMP/OPAGG 1$2r000,,Q0Q00 X POLICY PROJECT LOC $ ........ .........._ .... ...... ......�...�......_ �............_. .. _......�.. ,.......�......_. AUTOMOBILE UAB1Ur Y COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO HIRED AUTOS """"r ..... P ... ...... BODILY INJURY (Per person) $ ALL OWNED NON -OWNED BODILY INJURY AUTOS AUTOS .. � $ (Per accident) SCHEDULED _ PROPE GE AUTOS (PPr accvlenl,) AMA. ....... $..... ... .... ....... ... _...- .... . ...... . .,.�.� .... UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS -MADE AGGREGATE ....... ..... ......... ...,. .... ... ..., DEDUCTIBLE $ RETENTION $ $ ..... ............_.. ........_........,. ".�._ �IU WORKERSCOhFBJSATiON WC STATU- I ANDEYPLOYERSUANi1TY .1...TQRY. LIMITS .._)..... _. _Et3._._._. _.__ .....__ ...__..... ANY PROPRIETORPARTNEREXECUTNE OFFICERMEMBFR EXCLUDED? EL EACH ACCIDENT W—biyyi" N/A S If yes, describe under SPECIAL PROVISIONS below E L DISEASE - EA EMPLOYEE s EA...: DISEASE POLICY LIMIT S _ A Abuse/Molestation N N S0019GL000001-04 01/06/2025 01/06/2026 Each Occurrence: $ 100.000.00 Aggregate: $ 500,000 o0A0 .. ...... ............. ___,,,.._ ............. _. 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 - 01/0612026; ..._.�........�..,.. ....._._ ..-.............._. ..,_,_--.,...m.,.. ........ ............ 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 p 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 Lauryn Muraida. Date: By. Darrell George, City Manager g "' r�' r w 1 1� hr ; / y � H r t 4 r aGr � nr dvrre k E CU 'Y CALIFORNIA EVIDENCE OF LIABILITY INSURANCE INSU A NC , California Automobile Insurance Company A P.O. BOX 10730, SANTA ANA, CA 92711-0730 AGENCY: THE LIBERTY COMPANY (818) 914-3960 a POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE CAAP0000794251 12/01 /2024 06/01 /2025 YEAR MAKE VIN 2005 TOYOTA NAMED INSURED MURAIDA ADDITIONAL DRIVERS LAUREN MURAIDA s TO REPORT A CLAIM, please call (800) 503-3724 For access to ROADSIDE ASSISTANCE ONLY, please call (866) 519-6478 This policy complies with 610 6 or §16500.5 of the CA Vehicle Code. �" %#.38342 14 tt 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, LX_) 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 # LX) 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 provisions or the a reement wil automatically become void. Signature of Date 04/12/2024 Applicant Pr-! Lau!yn_Muraida Agreement for: Dated:: Reviewed by: