PROOF OF INSURANCE (2021) CLOSEDPage 1 of 1
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 06/05/2020
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 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 CONTACT Willis Towers Watson Certificate Center
Willis Towers Watson Southeast, Inc. PHONE 1 11 17
87 945-737?t 1 F
c/o 26 Century Blvd I� N fAO .... Na) BBB 467-2378
tlIEP.O. Box 305191 AOSS certificates@willis com .......... .....,.,..
Nashville, TN 372305191 USA INSURERA Everest National Isurnce Company 10120
INSURED INSURER B :.
American Youth Soccer Organization - AYSO Region 92
19750 S. Vermont Avenue ..INSURER C s
Suite 200 INSURER D s
Torrance, CA 90502
INSURER E ;:
COVERAGES CERTIFICATE NUMBER: W16757620 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.
...... ,...... POLICY E� ...,._..I Y ,.-- ........__, ._.... _ ........., ,._... _......
......._. _„ w ......�..
iiDL t)IRR FF POLICY EXP LIMITS
ILNTR ... ... ..TYPE �
OF INSURANCE. PQLIC.,.,
POLICY NUMBER MMIODIXYYX MM/DD(YYYY.
GENERAL LIABILITY
COMCLAIMS
EACH OCCURRENCE
S 1,000 000
MADEMERCIAL
CLAIMS -MADE X I OCCUR
.-.OATAA TOW04
PRE,M!,5 ',5„ F,�,q��.currren„crT)
,.,..,
w$_ 2 , 000 000
.
A
X
Participant S Legal Liabilit
MED EXP (Any one person)
$ 10,000
.�
..G.
- .... ����
Y
SIBML00321-201
07/Ol/2020
07/Ol/2021GENERALAPERSONALSADVINJU
.---- '__ .a.„.
Y
� $
EN'LAGGREGATELIMITAPPLIESPER:
__—
AGGREGATE
$ 3,000 000
.... ....
"I'D
PRODUCTS,
$ 9,,000 000
'........„
_.
POLICY JECT LOC
.... .... ,-COMP/OPAGG
„„ __,
X
OTHER.. Per Region (25M Pol Agg)
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Is
�... .
ANY AUTO
BODILY INJURY (Per person)
(
I{ $
OWNED SCHEDULED
INJURY (Per accident)
BODILY INJ
$
AUTOS ONLY AUTOS
NON -OWNED
PROPERTYPROPERTYHIRED DAMAGE
$
AUTOS ONLY I AUTOS ONLY
P r uccldsvu
....(...4f. ... 9I _... ,._.___. ,_
...... ..........
$
UMBRELLA LIAR X
RENCE
4 000 000
A
X
EXCESSLIAB CLAIMS -MADE
SIBEX00267-201
07/01/2020
07/01/2021
AGGR GATE _
$ „ 9 000 000
X
I RETENTION $ 0
1 $
WORKERS COMPENSATION
4EAR I OTH
R
AND EMPLOYERS' LIABILITY y / N
"•�
ANYPROPRIETOR/PARTNER/EXECUTIVE
E L EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
NIA
(Mandatory in NH)
)
E L DISEASE EA EMPLOYEE�11
If yes, describe underEL,
OF OPERATIONS below
(
DISEASE - POLICYDESCRIPTION LIMIT
A
Abuse S Molestation
SIBML00321-201
07/01/2020107/01/2021
Each Occurrence
$1,000,000
,Aggregate
$2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
*Med Pay applies only to spectators at an AYSO Event.
Certificate Holder is an Additional Insured as respects AYSO sanctioned events only, and where endorsement is attached
and required by contract.
General Aggregate Limit Applies on a per Region basis.
I-IUA I L HULULK L,#kNVCLLA I IUIY
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
The City of El Segundo, its officers, officials
employees, agents, and volunteers AUTHORIZED REPRESENTATIVE
VE
350 Main St 45
E1 Segundo, CA 90245
U 1yStf-ZU1 b AGUKU I:UKI'UKA I IUIN. AU rlgnis reserveu.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SR ID: 19696009 BATCH: 1702275
POLICY NUMBER: S18ML00321-201
COMMERCIAL GENERAL LIABILITY
ECG 20 600 05 09
THIS ENDORSEMENT CHANGES THE COVERAGE PART. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED AUTOMATIC STATUS WHEN
REQUIRED IN A'' RI°TTEN AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II — Who Is An Insured is amended to
include as an additional insured any person or or-
ganization with whom you have a written agree-
ment that such person or organization be added
as an additional insured on your Coverage Part.
Such person or organization is an additional in-
sured only with respect to liability for "bodily in-
jury", 'property damage" or "personal and advertis-
ing injury" but only to the extent caused, in
whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your operations for an addi-
tional insured.
B. The insurance afforded to an additional insured
shall only include the insurance required by the
terms of the written agreement and shall not be
broader than the coverage provided within the
terms of the Coverage Part.
C. The Limits of Insurance afforded to an additional
insured shall be the lesser of the following:
1. The Limits of Insurance required by the written
agreement between the parties; or
2. The Limits of Insurance provided by this Cov-
erage Part.
D. With respect to the insurance afforded to an addi-
tional insured, this insurance does not apply to
"bodily injury", 'property damage" or 'personal and
advertising injury" arising out of any act or omis-
sion of an additional insured or any of its employ-
ees.
ECG 20 600 05 09 Copyright, Everest Reinsurance Company 2009 Page 1 of 1 ❑
Includes copyrighted material of Insurance Services Office, Inc., used
with its permission.
INSURED COPY
memo
AYSO Region 92
To:
Shawn Green
From:
Shad McFadden, AYSO 92, Regional Commissioner
CC:
Monse Pafacios, Arecia Hester
Date:
3/4/21
Re:
Auto Insurance
Comments: This is to confirm that AYSO Region 92 does not have Auto Insurance as part of our insurance. We do
not rent vehicles for AYSO purposes.
Please reach out if anything additional is needed from us.
Thank you,
Shad McFadden
Regional Commissioner, Region 92
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:
(U 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 #
( X 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
Signature y comp y w p ovi ions or the agreement will automatically become void.
immediate)lom I with th ro' 3/3/21
Appl'
Date
ant McFadden
Print Name
Agreement for: Agreement #4814B
Dated: 3/29/21
Reviewed by: J L