PROOF OF INSURANCE (2022) CLOSEDAC. >R"`�DATEIMMIDD/YYY'Y'l
Iis��I INTIIFICATE OF LIABILITY INSURANCE 0113112020
THI'S'CERTIFICATE ISIS SUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT'IF'ICATE HOLDER. THIS
CE'RTI'FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT COIN STITUTE A CONTRACT BETWEEN THE ISSUING IIN SURER(S), AUTHORIZED
REPRE'SEN'TAT'I'VE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(fes) must be endorsed. It 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 heu of Such, endorsement(s).
PRODUCER CofrrACT
RPS Bollinger NOME:
150 JFK PARKWAY, 4TH FLOOR PHONE FAX
PO BOX 390 fAX, Ito Ext'y: 800.446.5311 JAM, tgo y: 973•91143474
SHORT HILLS, NJ 07078 E-MML
PHONE:1-SOCA46-5311 FAX: 973-921-8474
AAOREif:
I INSURER01 AFFORDING COVERAGE
MAIC IM
NKRMA: Markel Insurance Company 35970
INSURED INSURER B:
LISA Softball and Members of USA Softball of SoCal Indiv Peg,
Program
Phil Gutierrez Q °
PO Bax 5028 INS
Oceanside, CA 92052 wsulF:
COVERAGES POLICY CHANGE NUMBER: IR020 065249 REVISION NUMBER:
THIS IS TO CERTIFY 'THAT 'THE POLICIES OF IIdSU'R'ANC'E LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ASO'VEW FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REOUIR'EV:ENT, TERM OR CONDITION OF ANY CONTRACT OR CTHIFR DOCUMENT WITH R'ESP'ECT TO WHICH THIS CERTIFICATE MAY EE, 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.
INSR LIMITS
( TYPE OF INSURANCE POLICY NUMBER I
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DESCRIPTION OF OPERATIONS.i LOCATIONS F VEMCLE''S IAttach ACORD 101„ Ad'ditiona Remarks Schedule, if more space ds'w1egMairedl
COVERAGE UNDER THIS POLICY SHALL APPLY TO LIABILITY OF THE INSURED ARISING OUT OF THE ADMINISTRATION. PLAY OR PRACTICE OF AMATEUR SOFTBALL/BASEBALL,
BUT ONLY FOR INCIDENTS INVOLVING BODILY INJURY, PERSONAL INJURY OR PROPERTY DAMAGE. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED. THIS
CERTIFICATE IS ISSUED ON BEHALF OF: EL SSEGUNDO GIRLS SOFTBALL
CERTIFICATE HOLDER CANCELLAT'I'ON
The City of FJ Segundo, its olicers, officials, employees,, agents,.. and SHOULD ANY OF THE ABOVE' DESCRIBED POLICES BE CANCELLED
volunteers BEFORE THE EXPIRATION DATE THEREOF„ NOTICE WILL. BE DELIVERED IN
350 Nlain St. ACCORDANCE WITH THE POLICY PROVISIONS.
F1 Segundo, CA 90245
AUTHORIZED REPRESENTATIVE k rrf
® 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marls of ACORD
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION FOR
USA SOFTBALL ACTYVITIES
This endorsement modifies insurance provided under the folloming:
CONSERMLL CENT. kL HAMMY COVERAGf FORM
With respect to coverage provided bv this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
rA Softball aM ldembEra of USA SoftWl of SoCal lndm.
i%� Reg Prcgra
. C.
�ty of 'El Segundo, in officers, officials, employees, igerits, anii vclunteer5
Pofin, Number Policy Peried
3602; 30069 1.12020 -1i li2021
� I stued By Rapreienuii,.,e
.NLUWL LKSVILMNCE CONEP.MN-V
Tht Sbw"e mbMud" is rsqutnd only Vwben this 4txtonemiw is Vieptred di.,, VN policy is imkld
Name of Person or Organization-,
As Show on the Attacked Certificate of Insurance
A. The follomingis added to Section, 11-WHOISANT INS URM
Eridoffseffbare Efecdw Date
As stumm an the stuched Ceftifime offlnewmrp
The person or organization shown in the above SC ULE but only,%ith respect to liability arising out of the organization,
promotion, administration and conduct of amateur softball acti%ities including games:, practices, tournaments, and fund-raising
activities, under the rules of the USA Softball, provided:
a. That if the person of organization is designated as a Teams, the person or organization so designated shall be deemed to
include team members, managers, coaches, assistants, batboys, registered scorekeepers, sponsors, arry other individual
participating in the official ftinctions of the team„ and if so indicated, a Field O%ner, but only for liability arising out of the
designated Team's amateur softball actnities covered under this policy:
b, That if the person of organization is designated as a League, the interest of the League shall not be included urdes s aft reams
in the I eague purchase this insurance. When the interest of the League is so included, the person at organization designated
as a League shall be deemed to include all teams in the league and team members, managers, coaches, assistants, batboys,
rep' y such
gisteted scorekeepers, sponsors, any other individual participating in the official functions of the League or of anN
teams, and if so indicated, a Field Neter, but only for liability arising out of the designated League's amateur softball
activities covered under this policy-,
Al other terms and conditions of this policy remain unchanged
7/1.5 /f
f
5e5V� Sa�f
1
Y\,�SC75
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:
(_„_} I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
i of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
, with the City of EI 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 #
t2 certify that, in the performance of the work set forth in the agreement with the City of EI 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 triose provi io s -of the agreement will automatically become void.
igpptureofApplicagi Date ? f�
r
Agreement for:
Dated: _P
Reviewed by: