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PROOF OF INSURANCE (2025 - 2025) CLOSEDAC DATE (MM/DDIYYYY) �' CERTIFICATE OF LIABILITY INSURANCE 02/27/2025 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 PRODUCER CONTACT The Camp Team NAME PHONE FAX(303) 422-1276 9035 WADSWORTH PKWY STE 3820INC,Ne- Ex'c : A/c• Ne WESTMINSTER, CO 80021-4541 E-R1AIL. ADDRESS:.. INSURERS) AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Company 16691 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B : ITS PARTICIPATING MEMBERS: City Of El Segundo wsuRERc, 650 MAIN ST rINSURERD;EL SEGUNDO, CA 90245 SURERE SURER F a :OVERAGES CERTIFICATE NUMBER: GAS159347 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE[ INDICATED. NOTWITHSTANDING ANY REQUIREMENT„ TERM OR CONDITION OF ANY CONTRACT OR OTHE THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DES TF'aRM.q FXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID 7W TYPE OF INSURANCE GENERAL LIABILITY ��- X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Ex] OCCUR A X HOST LIQUOR LIABILITY INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: '"j PRO- X I POLICY I I xr•LOGA AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTO NON -OWNED AUTOS UMBRELLA LIAB I I OCCUR EXCESS LIAR F1 CLAIMS -MADE DIED I I RETENTION $ POLICY NUMBER PAC 4725038 04/12/2025 � 04/13/2025 12:00 AM 12:01 AM PAC 4725038 04/12/2025 04/13/2025 A Professional Liability 12:00 AM 12:01 AM DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covered Activities: Author Talk Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage RFVICIAN NIIIhd.1RIPP- I NAMED ABOVE FOR THE POLICY PERIOD R DOCUMENT WITH RESPECT TO WHICH -RIBED HEREIN IS SUBJECT TO ALL THE CLAIMS, LIMITS EACH OCCURRENCE $1,000,000 OMwbFAGE 1°0 PERT-0 $300,000 PPEM Pak5' Ica ="b coY MED EXP (Any oneperson) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $1,000,000 PRODUCTS - COMP/OP AGG $1,000,000 nJarv�-BIW&?kA 3YpGC�LE Lrr�pur ��- BODILY INJURY (Per person) BOOIL'Y INJURY (Per "61.CIrJew P%2 PERAW^R7AM,9fwL"H?, (per are' 3w EACH OCCURRENCE AGGREGATE EACH OCCURRENCE $1,000,000 AGGREGATE LIMIT $1,000,000 CERTIFICATE HOLDER CANCELLATION Proof Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _r ti,& C"If.' _r a.vw ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 2018 SUBARU FARMERS FORSTR 4x4 WEE 2.51 TOURING NC E INSURED(S) J R Y A N zr")"T R A D'A L POLICY NUMBER EFFECTIVE 523837973 12/09/2024 - VIN STATE CA w 06/09/2025 FARMERS InsuranceAuto Declaration Page III NSLUiRANt:IE Policy Number: 52383-79-73 Effective: 12/9/2024 12:01 AM Expiration: 6/9/2025 12:01 AM Named Insured(s): I Rvan Strad al e e-mail Address(es): Underwritten By: Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills, CA91367 Premiums/Fees Policy Premium .. N M $1,938.00 Fees (*also see Information on Additional $0.88 Fees below) Ipollliicy PoI°erniuuuurym and Fees This is not a bill. Household Drivers All persons who drive or will occasionally be driving any of the cars on the policy should be listed below. If anyone is missing or needs to be added, such as a newly licensed driver, you should contact your agent or the company to add that person before they begin to drive any of the cars covered on the policy. Name DriverStatus Name Driver Status JRyan Stradal Covered ' �� Covered Vehicle Information Veh. # Year/MakelModel/VIN 1 2018 Subaru Forstr 4X4 W/E 2.51 Touring Coverage Information Limits Coverage (applicable to all vehicles_) Bodily Injury Liability $100,000 each person $300,000 each accident Property Damage Liability $100,000 each accident Permissive User Limit of Full (See Permissive User Liability** Limit of Liability in your policy) Medical Coverage Uninsured Motorist Bodily Injury Comprehensive Collision Additional Equipment $100,000 each person $300,000 each accident Coverage Deductible Comprehensive: $250 Collision: $500 Additional Equipment: Limit $1,000 Premiums by Vehicle Vehicle 1 $617.00 $323.00 Included Not Covered $127.00 $185.00 $568.00 Included faurirtrieurs.coirn II No. 52383-79 73Questions? Mair%ageyouraccount: Call your agent Sheila R Kamps Go to www.farmers.com to access Insurance Agency Incorporated at your account anytime! (559) 221-5160 or email 56-6176 end Edition 3-19 10/15/2024 skamps@farmersagent.eom Pagel of 3 Declaration Page (continued) Premiums by Vehicle Limits Coverage (applicable to all vehicles) Vehicle 1 Uninsured Motorist Property $1 1.00 Damage with Collision Towing and Road Service $12.00 Glass Deductible Buyback $15.00 Loss of Use K5: $50 per day/ $1,000 $80.00 max -�-..---_ .... ...._._..... � �, ._...... .... Total Premium Pert/ehicle _ � . .. . $1 938.00 Policy Premium $1,938.00 Fee Detail Vehicle 1 Total Anti -Fraud Fee _ $0.88 $0.88 Fees $0.88 Policy IIPireirniurrr aind Fees $1,938.88 Discounts Discount Type Applies to Vehicle(s) Discount Type Applies to Vehicle(s) Safe Driver All Good Driver All Stability Control All Auto/Home All Anti -Lock Brakes All Rating Information Details Vehicle 1 Garaging Zip 91501 Renewal Term 12-Month Mileage 11,400 Expiring Term 12-Month Mileage 9,900 Vehicle Usage Other Use Years of Driving Experience 29-33 Policy and Endorsements This section lists the policy form number and any applicable endorsements that make up your insurance contract. Any endorsements that you have purchased to extend coverage on your policy are also listed in the coverages section of this declarations document: 56-56841st ed.; 25-45018-11; 25-8531 10-12; CA1 25 3rd ed.;J69603rd ed.;J77241st ed.;J69622nd ed. faurmers.com Polflcy No. 5 38:3.79 73 r uestioins7 Mairnage your accouint. Call your agent Sheila R Kamps Go to www.farmers.com to access Insurance Agency Incorporated at your account anytime! (559) 221-5160 or email 56-6176 2nd Edition 3-19 skamps@farmersagent.com Page 2 of 3 Declaration Page (continued) Other Information • "YOUR POLICY INCLUDES THE FULL PERMISSIVE USER LIMIT OF LIABILITY. PLEASE SEE PERMISSIVE USER LIMIT OF LIABILITYIN YOUR POLICY FOR FURTHER INFORMATION. • Vehicle 1 - Deductible reduced to $100 for glass loss. • 2018/Subaru/Forstr 4X4 W/E 2.51 Touring is a customized vehicle. • You have the right to designate an additional third party to receive any notice of cancellation for nonpayment of your premium for this policy. Please contact your Farmers® agent if you would 1Cke to add, change, or remove a designee. • Farmers Friendly Review® appointments area great way to make sure you are receiving all the discounts for which you qualify, and identify any potential gaps in coverage. Contact your agent to learn more about the policy discounts, coverage options, and other product offerings that may be available to you. *Information on Additional Fees The "Fees" stated in the "Premium/Fees" section on page 1 apply on a per -policy, not an account basis. The following additional fees also apply: 1. Service Charge per installment (Inconsideration of our agreement to allow you to pay in installments): For Recurring Electronic Funds Transfer(EFT): $0.00 (applied per account) - For Recurring Credit/Debit Card plans: $5.00 (applied per account) For all other payment plans: $7.00 (applied per account.) If this account is for more than one policy, changes in these fees are not effective until the revised fee information is provided for each policy. Countersignature �F f 1 Authorized Representative farmers.com Policy No. 52383•-79-73 56-6176 Znd Edition 3-19 2. Late Fee: $15.00 (applied per account) 3. Returned Payment Charge: $25.00 (applied per check, electronic transaction, or other remittance which is not honored by your financial institution for reasons including, but not limited to, insufficient funds or a closed account) 4. Reinstatement Fee: $18.40 (applied per vehicle, 20% discount wi II apply for Good Drivers) One or more of the fees or charges described above may be deemed a part of premium under applicable state law. Questions" Call youragent Sheila R Kamps Insurance Agency Incorporated at (559) 221-5160 or email skamps@farmersagent.com Manage your account: Go to www.farmers.com to access your account any time! Page 3 of 3 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. (_) 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 immediately comply those provisions or the greement will automatically become void. Signature of Applicant SDate -- Print Name Agreement for: Dated: Reviewed by:.