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PROOF OF INSURANCE (2021) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/13/2020 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), yyI PRODUCER CONTACT I MF: I RPS Bollinger -Sports & Leisure PHONE E800-446-5311 FAX ) 973-921-8474IAIC�No� Y INS N2 1 150 JFK Parkway E-MAIL PO Box 390 wt Short Hills, NJ 07078-5000 PRODUCER l C0IOMER ID #,: INSURER(S) AFFORDING COVERAGE NAIC # 1 INSURED INSURERA: Markel Insurance Company 38970 US Lacrosse, Inc. INSURER B: 2 Loveton Circle INSURER C: Sparks, MD 21152 INSURER D: Re: LAYLL INSURER E: 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. INSR POLICY NUMBER ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS LTR INSR WVD lMMIDDIYYYYI_IMM/DOIYYWt GENERAL LIABILITY EACH OCCURRENCE 1 000 000 A X COMMERCIAL GENERAL LIABILITY X 8502AH221369 01/01/20 01/01/21 DAMAGE TO RENTED 000 0 0 CLAIMS MADE X 1 OCCUR, Sexual Abuse and Molestation coverage is afforded Nith Limits of Liability of $1,000,000/oc :urrence and $2,0011,000 aggregate. MED EXP (Any one person) $10,000 X Incl, Participants PERSONAL&ADV INJURY S1 000 oo GENERAL AGGREGATE $5.000„000 1 POLICY AGGREGATE EGPRn LOC LIMITAPPLIES IECOMBUNED S NGME ®MIAGG 2 12,000,000 AUTOMOBILE LIABILITY (Ea accident) ANY AUTO I BODILY INJURY (Per person) I ALL OWNED SCHEDULED I BODILY INJURY (Per accident) u AUTOS AUTOS �. HIREDAUTOS NON -OWNED I PROPERTY DAMAGE _ AUTOS dPer accidentl A UMBRELLA LIAB I X I OCCUR X 4602AH221370 01/01120 01/01/21 I EACH OCCURRENCE $2,000,,000 X EXCESS LIAB CLAIMS MADE AGGREGATE $2,000,000 I DED n RETENTION $ WORKER'S COMPENSATION WC STATU- OTHER AND EMPLOYERS' LIABILITY YIN I TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E L EACH ACCIDENT OFFICER/MEMBER EXCLUDED? BMin NH) SE - EA EMPLOYEE Mandatory 00 EL DISEASE t yes, describer under E -POLICY LIMIT DESCRIPTION OF OPERATIONS below A Accident Medical 4102AH025220 01/01/20 01/01/21 Ace Limit $100,000 A Catastrophic Ace 4102AH305882 01/01/20 01/01/21 Cat. Ace $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Coverage applies only to teams/leagues comprised of 100% US Lacrosse member players and coaches during scheduled & supervised lacrosse activities. Certificate Holder is named as an Additional Insured. Certificate is issued on behalf of LAYLL. The City of EI Segundo, its officers, officials, employees, agents and volunteers are named as additional insured . CERTIFICATE HOLDER City of EI Segundo 401 Shelton St. EI Segundo, CA 90245 0000 CANCELLATION 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+ ©1988 - 2009 ACORD CORPORATION, All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 8502AH221369 US Lacrosse, Inc. 1/1/2020 - 1/1/2021 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATIONI This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organization(s) City of EI Segundo 401 Shelton St. EI Segundo, CA 90245 0000 The City of EI Segundo, its officers, officials, employees, agents and volunteers are named as additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II —Who Is An Insured is B. With respect to the insurance amended to afforded to these additional include as an additional insured the insureds, the following is added to person(s) or organization(s) shown in Section III — Limits of Insurance: the Schedule, but only with respect to liability for "bodily injury", "property If coverage provided to the damage" or "personal and advertising additional insured is required by injury" caused, in whole or part, by contract or agreement, the most we your acts or omissions or the acts or will pay on behalf of the additional omissions of those acting on your insured is the amount of insurance: behalf: 1. In the perforamce of your ongoing 1. Required by the contract or operations; or agreement; or 2. In connection with your premises 2. Available under the applicable owned by or rented by you. Limits of Insurance shown in the Declarations; However: whichever is less 1. The insurance afforded to such additional insured only applies to This endorsement shall not increase the extent permitted by law; and the applicable limits of Insurance 2. If the coverage provided to the shown in the Declarations. additional insured is required by a contract or agreement, the insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 Copyright Insurance Services Office, Inc. 2012 Page 1 of 1 EI Segundo Youth Lacrosse 409 E. Oak Ave, EI Segundo, CA 90245 (310) 227-5112 Aug 31, 2020 To Whom It May Concern, EI Segundo Youth Lacrosse (both boys and girls divisions) do not sue automobiles in the running of our programs. Therefore, we do not feel that we need to carry any automobile insurance. Please contact us with any questions, Regards, Brooks Roscoe Executive Director EI Segundo Youth Lacrosse ffYE-O N'y. i. .. FAILURE RE ' O SECURE 1. i KE Rx { IS UNLAWFUL AND SU&JECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (WO,000), IN ADDITiON TO THE COST OF COMPENSATION, Y" 4 7 5X ',' PROVIDED .Dy. FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEYsS FEES. l affirm under penalty of periury under the laws of California one of the following declarations: (_)I have and will maintain a certificate of consent of self -insure for workers' compensations, 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. W I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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 # V (_011 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 Califomia, 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 �.;a. `� _ Date Agreement for: •O Dated:' Reviewed by: