Loading...
PROOF OF INSURANCE (2025 - 2025)__ 0611 202� . .... .... . ......4 Y) .,._. AcoRl ► T /�T........ LITY INS. CC — CER 1 IFIC-A E OF LIAB..I ��NyGON THE CERTIFICATE H DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS OLDER. 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. IMPORTANcertificate holder is an ADDITIONAL INSURED, the must be endorsed. If SUBROGATION T: If the P Y(� olic les) 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 NAME FAX .. ...L 't_t�4a,,..9......... Myers -Stevens & Toohey 8 Co., Inc. PHOPHONE... - - B00827-4695 48-2630 to .f1 t .M1 .. _ 949 3 - _... E-MAIL DS ss: mt,ochey myers--steuens co1m 26101 Marguerite Parkway, _ _ ...,__ ., . .. Mission Viejo, CA, 92692 GStt? ;. -- .. ... .... . NAIG # ........_ ......... ...._........ ..___ .....� ...m...._. ........... .... .,-.... .. .__..INSURER(S�APFORDING COVERAGE... ....____ ....___ INSURED Sports Marketing Program Management Inc. I . ..m__ ...- .. .....�.... INSURER B . 12655 Bluff Creek Drive #120 INSURER ..._C ... .... - ... --- .... ......._ ......�_.... INSURER D C Playa Vista, CA, 90094 11._.... __. .. .... ...... _ — — INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER A-SP- Ui-24-04-12w30276 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, POUCY0PF Poit. r,NITS TYPE,Q,¢„ fflSUFiANCE', ADM SUM',....,,,. POt 9'D.4" N!&�fA.f�. _.m.. ........ tnti__. ... .. GENERAL LIABILITY OCCURRENCE ,$ °)(�1'()I,1( A Y N BESGLPTNVOI1301_170012_02 06/11/2024 O6/11/2025 EACH GENE _._�.._ ... X, COMMERCIAL GENERAL LIABILITY FIRE DAMAGE TO PREMISES $ 300,000.00 TpjED AnEane vnll5 CLAIMS -MADE X OCCUR $0. EXPNCLUDES ATHLETIC PARTICIPANTS PERSONAL 8 A,DV N URIY $ 1 000 000 00 GENE�._, RALAG_REGGATE 3UOQ,9Q QQ ,,, w GENERAL AGGREGATE LIMIT APPLIES PER: ,PRODUCTS COMPIOP AGG g 2'tI OA (jO POLICY [—] PROJECT � LOC ....._..... .._......_ .....,.. - ....... _.._.._....-......... AUT OMOBILE LIABl1TY COMBINED SINGLE LIMIT ANY AUTO HIRED AUTOS (Ea accident) $ ,.___..... .....,._.._ ..� . .....,, ......... ,�...._. ALL OWNED NON-OWNEDAUTO. BODILY INJURY (Per person) $ AUTOS ...BODILY INJURY .(Per accident) $ ......."""""".._..__. ...-.�..-- SCHEDULED PrSr cdde .. ... PROP DAMAGC AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE .. EXCESS UK .. CLAIMS -MADE ....... AGGREGAT�.. _ _., ..... ... ....� ........ ._-- DEDUCTIBLE. ......... .,.. RETENTION $.............-......................-...............$...._—_—....-, NIOf71�SCOMPENSATION i STATU• I"Y ANDBYPLONH75 LIABILITY... w6G'Jk'tY..LlktEli'".��� C.R.. ..._ ..,. OFFICERMEtuBER EX CLIP? E,L, EACH ACCIDENT S (MandaEryir NFl) N / A If yes, describe under SPECIAL PROVISIONS below F L. . EA Q$CASE'..EMPLOYE $ ...._�.....,�,.. .....E... .......� E L l7MSEASE - PDL!EC LIMIT 5 _ OTHER A Abuse/Molestation Y N BESGLPTNV011301_170012_02 06/11/2024 06/11/2025 Each Occurrence: S 25.000.00 Aggregate: $ 50,000.00 ..III.,.-............ .... ....... - ...... 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. The certificate holder is named as Additional Insured with respect to (continued on next page) CERTIFICATE HOLDER CANCELLATION City of El Segundo. its officers, officials, employees, agents and volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 350 Main Street DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA, 90245 - AUTHORIZED REPRESENTATIVE 1� / Mark Di Perna ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ©1988- 2009 ACORD CORPORATION. All rights reserved. ....------ ... ................. AGENCY - ........ ................_ ... _ .... ...... ............ NAMED INSURED Myers -Stevens & Toohey & Co., Inc. ....�.�.�.�,... ... ..m........-- ...�..... ....- Champ Camp LLC POLICY NUMBER .... ..._._._. 12655 Bluff Creek Drive #120 BESGLPTNV011301 170012 02 Playa Vista, .... ......... ..... .... ...... .._ ......... ....... ..,....._ -------- CARRIER NAIC CODE CA90094 , Texas Insurance Company16543 .... ........ .... ..._n,.,__.— ......�.......,_. . EFFECTIVE DATE: 06/11/2024 annJT'1nb1AI RFMARKC .................... ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ©1988- 2009 ACORD CORPORATION. All rights reserved. POLICY NUMBER: BESGLPTNV011201_170012_01 CERTIFICATEM A-SP-SU-23-05-12-276834 NAMED INSURED: Champ Camp LLC POLICY PERIOD: June 11, 2023 to June 11, 2024 COMMERCIAL GENERAL LIABILITY CG 2011 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS O LESSORS S OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Ref: Champ Camp LLC Name Of Person(s) Or Organization(s) (Additional Insured): Any person or organization if required by an insured contract provided such contract was executed prior to the occurrence or offense. City of El Segundo 350 Main Street El Segundo, CA, 90245 Additional Premium: $ Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. However: 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance 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 Section III — Limits Of Insurance: 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; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted by This endorsement shall not increase the law; and applicable Limits of Insurance shown in the Declarations. CG 2011 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 IMG-2514.JPG 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 § 3708, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under 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. (_) 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 # dI 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 mann eb ' o become subject to the worWdrs pensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § X 0 I must I with those ovision or t e agreement will automatically become void. immediately comply °� ..... -� ,� Signature of Applicant Date A 7_1 a r rs� Print Name Agreement for: Dated: Reviewed by: