PROOF OF INSURANCE (2021) CLOSED• • 1 r'
CERTIFICATE OF LIABILITY -INSURANCE
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RIPS Bollinger
Whippany,07981
PHONE:80I > 4 { 9 , 1
ADSS:
INSURER(S) AFFORDING COVERAGE NAIC
IN A: Markellnsura Company 39970
INSURED S:
USA Softball and Members of USA Softball of SoCal Indiv Reg INSUFERC:
Program
Mike SCi1UCk Kristi Allen IN la:
PO Box 5028
Oceanside, CA 92052 IN StiffilleR F
COVERAGES POLICY CHANGE NUMBER:IR0202169825 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED LD(W HAVE EN ISSUED TO THE INSURED NAMED ABOVE FOR THE ICY PERIOD INDICATED.
NOTWITHSTANDING ANYREQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED
OR MAY PERTAIN, THE INSU RANGE 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
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TYPE OF INSURANCE
AIDDIL
IR
UND
POLICY NUMBER
Y EFF
Y EMP
LIMITS
GENERAL LIABILITY
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EACH occu
000 000
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51.000,000
S1 ®,IBI70'
A
COMMERCIAL NE LI II..ITY
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CLAIMS -MADE OCCUR
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300 1I20,2I
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Participants Liab
-Non-participants only
�Cd�kPADVRJURY
SZ000,000
CEIIAM&MG- GATE
S5.000.000
GEN"L AGGREGATE LIMIT APPLIES PER:
K111LICY PRO- x LOG
IECT
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of �Iia,C. ifi
PRODUCTS-CCWK)PAC-*
S2,000.000
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AUTOMOBILE LIABILITY
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ANY AUTO
ALL OOINED
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AUT AUTOS
HIREDAUTOSqSCHEDULED
NON-OWNED
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AUTOS
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UMBRELLALIAB OCd UR
FACM0 CF
EXCESS LIAR 0-A105-
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F.GGRECATE
S
D ERETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LUlBI
ANY �� LrfY
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OPEFAMON5 WON
OTHER
OFSCRIPTIO14 OF OPERATIONS J LOCATIONS d VEHICLES IAttach ACORD 101, Additional Remarks Sthedule,'0 more space is regluired,l
COVERAGE UNDER THI S POLICY SHALL APPLY TO LIABILITY OF THE INSURED ARISING OUT OF THE ADMINISTRATION. PLAY OR PRACTICE OF AMATEUR SOFTBALUBASEBALL,
BUT ONLY FOR INCIDENTS INVOLVING BODILY INJURY, PERSONAL INJURY OR PROPERTY - CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED. THIS
CERTIFICATE I $ ISSUED ON 'BEHALF OR EL SEGUNDO GIRLS SOFTBALL
CERTIFICATE HOLDER C:AN(;tLLAIK)N
The City of El Segundo, its officers, officials, employees, agetats. and SHOULD ANY OF THE ABOVE DESCF4BED POLICIES BE CANCELLED
volunteers BEFORE THE EXPIRATION DATE THEREOF„ NOTICE WILL BE DELIVERED INI
350 Main SE ACCORDANCE MTH THE POLICY PROVISIONS.
El 5eeuxldoe CA 90215
.. AUTHORIZED REPRESENTATIVE
® 1988-201E ACORD CORPORATION. All rights reserved.
ACORD 25 t201W03) The ACORD name and logo are registered marks of ACCORD Digitally signed hyJoseph Ullio
Joseph Lillio Dean 1 Qkoc.WlFls ��satOffi
5agaa+adkl,asue um'Irrta�plYrnaryrk,tRty4%Scer,
dnti�,7pYh,�d@Ir 1uv61weuJun�1,0.+asa3. a�r15
Date: 2021,04.13 10:31:16-07'00'
.,3602AH230069 COMMERCIAL GENERAL LIABILW
TWIS EVD0i*SUENT CYANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Insured Person(s) Or Organization(s):
The City of EI Segundo, its officers, officials, ernployees, agents. and volunteers
Information requiredto complete this Schedule, if not shown above will' be shown in the E eclarafiens,.
JL
A. section R - Who Is An Insured is amended to include as an B. With respecetto the insurance afforded to these additional
additional insured the person(s) or organization(s) shown in insureds, the following is added to Section III - Limits Of
the Schedule, but only with respect to liability for 'bodily injury", Insurance:
.property injury" or "personal and advertising injury" caused, in if coverage provided to the additional insured is required by
whole or in part, by your acts or omissions or the acts or a contract or agreement, the most we will pay on behalf of
omissions of those acting on your behalf. the additional insured is the amount of insurance:
1. In the performance of your ongoing operations; or
2. In connection with your premises owned by or rented to
you.
However:
1. The insurance afforded to such additional insured only
applies to the extent permitted by law; and
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
agreementto provide for such additional insured.
1. Required by the contractor agreement; or
2. Available under the applicable Limits of Insurance
shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits
of Insurance shown in the Declarations.
CG 20 26"13 Copyright, Insurance Services Office, Inc_, 20-12 Page 2 of 2
To: City of El Segundo
RE: Auto Insurance
3/7/2021
JL
This letter verifies that the El Segundo Girls Softball Organization does not own or operate any street
legal vehicles. We have no need to carry Auto Insurance.
Please feel free to contact me if you have further questions on this matter.
Ian Wilson
President ESGS
310-702-1441
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO.SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPL&EFt 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.
J affirm under ia&MO of Perjury urdler the laws of cambrnia one of the b0owirrg t=s: _
(_) 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.
LJ 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 #
( I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
m) loy 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
y will automatically become void.
Signature of Applicant Date
the agreement
immediately comply with prow
Print Name
Agreementicr ,.
Dated: 04-13-2021,�...._.,w.
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