PROOF OF INSURANCE (2021) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/OO/YYYY)
1 11/22/2019
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 LEONARD ZAHLER CA 0324698 CONTACT LEONARD ZAHLER CA BROKER LIC. 0324698
PHOENIX INSURANCE SERVICES PHONE- - --- __....._.____....
??C"no..kxt),661 ti c.No):661) 8854244
ZAHLER INSURANCE AGENCY E-MAIL AOL.COM
RO. BOX 20545 INSURERS) AFFORDING COVERAGE NAIC #
INSURERA:F HILADELPHIA INSURANCE COMPA ------"-'-1735----
_ . _ --_ INSURANCE
---- --- ---------
BAKERSFIELD, CA 93390_. ----___- -- -- NY 17354
---_ _ ._.sou - - --------. _.. - -- - ----__ _ __..--- -------------
INSURED INSURERB:MUTUAL OF OMAHA INSURANCE CO. 03255
THBAY SOCCER REFEREE ASSOC. --- ---- ----- - —----- -
C/O MR. BRUCE ASHTON INSURERC:
9045 HARGIS STREET INSURERD:
LOS ANGELES, CA 90034 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
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.
LTR
. . _ _._
AD£)L'SUBR
TYPE OF INSURANCE €NSD WVr1 ... _
POLICY NUMBER
.__..-_-_.-____-_------__-__-_---------
-------CY E%P l
I(MM--- ----— 1MMIDOIYYYYI
A
} �( COMMERCIAL GENERAL LIABILITY
-__ X X PHUB461338
I._...
'
01101/202001/01120211 EACH OCCURRENCE ! $ 1.000,000
DESCRIPTION OF OPERATIONS below
j
cLAIMs•MADE X� occuR
..._.__._.
DAMAGE TO RENTED
1-00,000
1$
. _
ACCIDENTAL MEDICAL
PR €nIsFSSFa,occurrerce}—._. ;.s — --- _
ACCIDENTAL MEDICAL
$ 25,000
MER EXP (Any one person) $
PAYMENTS N REFEREES
ACC. DENTAL/ THEFAPY/
PERSONAL & ADV INJURY $ 1,000,000
! GEN'LAGGREGATE LIMITPLIES PER.
GENERAL AGGREGATE
$ 3,000,000
; PERQ--"
J ' LOC
PRODUCTS COMP/OP AGG
$ 3,000,000
I_X�POLICY
, I OTHER:
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (ACORD 101, Additional Remarks $0heiloW, may € e attached if more space is required)
ALL ACTIVITIES OF THIS INSURED,
I AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
AUTO'i
(Ea accident)
ANY
! BODILY INJURY (Per person) $
�
OWNED
--�` AUTOS ONLY
.I SCHEDULED
);' AUTOS
BODILY INJURY (Per accident) $
HIRED 1
AUTOS ONLY
NON -OWNED
AUTOS ONLY
-----------------_--'�.__.----------__.._... _._._..
PROPERTY DAMAGE
! jeer accitlent $
UMBRELLA LIAR I OCCUR
EXCESS LIAR CLAIMS -MADE
DED 7 1 RETENTION S
EACH OCCURRENCE
AGGREGATE
WORKERS COMPENSATION
1 PER OTH-
i AND EMPLOYERS' LIABILITY Y / N
! ANY PROPMETORrPARTNERIEXECUTIVE
;STATUTE (ER
IOFFICERIMEMBER EXCLUDE D? Li NIA j
E.L. EACH ACCIDENT
CHAC-----
$---
(Mandatory in NH)
�` If yes, deseAbe under
:. E.L. DISEASE - EA EMPLOYEE
:---------------------------__�
$
DESCRIPTION OF OPERATIONS below
E L DISEASE - POLICY UM€T
1$
B
ACCIDENTAL MEDICAL
T5MP-09610301/01/202001/01120211
ACCIDENTAL MEDICAL
$ 25,000
PAYMENTS N REFEREES
ACC. DENTAL/ THEFAPY/
ACC.
LOSS OF LIFE $ 1%0001
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (ACORD 101, Additional Remarks $0heiloW, may € e attached if more space is required)
ALL ACTIVITIES OF THIS INSURED,
ADDITIONAL INSURED: THE CITY OF EL SEGUNDO, CA - ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND
VOLUNTEERS ARE HEREBY NAMED ADDITIONAL INSUREDS,
30 -DAY WRITTEN NOTICE SUBMITTED TO CERT. HOLDERS AND ADDITIONAL INSUREDS IF POLICIES TERMINATE PRIOR TO
EXPIRATION DATES SHOWN ABOVE. ENDORSEMENTS ATTACHED HERETO.
CERTIFICATE HOLDER
CANCELLATION
SHO ANY O THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE CITY OF EL SEGUNDO, CALIFORNIA EXPIRATIO DATE THEREOF, NOTICE WILL BE DELIVERED IN
C/O SHAWN GREEN, RECREATION SUPERVISORACCORDANCE W H THF P�CY PRO IONS.
350 MAIN STREET, EL SEGUNDO, CA 90245
AU7HORIZEOR
LEAD ZA T 032
ACORD 25 (2016103)
b 1988-;t01"CORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of
SCHEDULED ADDITIONAL INSURED -PRIMARY
A
This endorsement modifies insurance provided under the ;,6110%ing:
COMMERCIAL GENERAL LIABIU —I, COVERAGE POL PHUB461338
pRODUCTSICOMpLET,ED OPERA -1101\,S,.LABILrryCOVERAGE
SCHEDULE
The City of El Segundo, its officers, officials,
Employees, Agents and Volunteers are hereby named
Additional insureds.
Who is an linsurecr is amended to include as an insured me pe=n or organization stiown in the
SdieWe as an Adctitiortal Insured, but only with resile a tri liability arising out of 'your WOW or
your product' which is imputed to the Additional Insured.
The insurance provided to the Additional insured under this endorsement is limited as fbfiows.-
1 The person or organization is only an additional insured with respect to liability arising
solely out cf,^yotr work' or 'your producf which is imputed to The Additional ln=*ed-
2, Any coverage provided by this endorsement to an Additional lnssvr'ed shall be primary and
n0n=#nbuWry with respect to any other valid and collectible insurance available to the
Additional Insured, provided tiat the written contract or written agreement specffmalty
requires that this insurance apply on a prirnary and noncontributory besis.
3. In the event tial the Urnits of Insurance provided by this policy exceed te Lin-fft Of
Insurance required by the written contract or written agreement the lnsurane e provided by
this endorsement shelf be limited to the Limits of Insurance required by the written =tact
or written agreemerit. This endom-em ent she]l not increase the Limits of lnsunnce stated in
the Declarations_
4_This insurance does not appy to 'bodily injury or 'properr
� y damage' arising out of 'your
worth or 'your producf included in the products — completed operons ham unkm
you are required W provide such coverage by written contact or written agreement but only
for the period of time required by the written contract or written agreement and only for
'bodily injury? or 'property damage' that occurs during the policy period ad". out of 'your
wore or 'y(xr producr.
5- Where no coverage snail apply herein for the Named Insured, no coverage or defense shell
be afforded to the Additonal Insured.
S. This insurance does not apply to "bodily Injury' or 'property damage arising out of
a. the sole negligence of the Additional Insured,
b- the sole negligence of any employee of the Additional Insured: or
c- any obligaton of the Additional Insured to indemnify another because
of damages arising out of such injury or damage,
ALL.OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
AP2057US G3-07 Page 1 o'tl
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION WHEN REQUIRED IN A WRITTEN
CONTRACT OR AGREEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL
GENERAL LIABILITY CONDITIONS) is deleted and replaced by the following:
We waive any right of recovery we may have against any person or organization against whom you have agreed to
waive such right of recovery in a written contact or agreement because of payments we make for injury or damage
arising out of your ongoing operations or 'your work' done under a contract with that person or organization and
included in the "products -completed operations hazard".
CG7555(11-04) IWudes copyrighted mate" of ISO Properties, Inc. with its pennissiom page 1 of 1
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
A
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
Name of Agent
Policy Number Expiration Date
Phone #
(Yo 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 agreement will automatically become void.
Signature of Applicant Date 6 -1 r - Zav�
—
Agreement for: 5CW Pr.661,i i PO4,57+),
A00n
Dated: 0/
Reviewed by: