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PROOF OF INSURANCE (2022) CLOSED^ Page 1 of 2
1 DATE(MMIDD/YYYY)
CCORL> CERTIFICATE OF LIABILITY INSURANCE 06/30/2021
s. tt--.
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....................
FAX
87..... -7378 1 888 467-2378
c/o 26 Century Blvd 1
tA^� �p� %Ik
E-MAIL certificates@willis com
P.O. Box 305191 ADDRESS
Nashville, TN 372305191 USA INSURERfSI�NAIC#
INSURED
American Youth Soccer Organization - AYSO Region 92
19700 S. Vermont Avenue
Suite 103
Torrance, CA 90502
RA Global Specialty S5 n �B0783
INSURER Everest National Insurance Co a y10120
INSURE„ B HDI„ .......„. p y .
INSURER C s „
INSURER D c
INSURER E
INSURER F
rnvconr-oc rI=DTICIr ATr- miiRARFR• W21475857 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.
.....--.....�.�. S9.IBR ... —� �.. _
.......TYPE
EFF ..MMIDD EXP ...... LIMITS
ILTR
�....
POLIC...........
OF INSURANCE...
X NUMBER MMIDD
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
I $ 1,000,000
j .....
2 000,000
X
CLAIMS -MADE OCCUR
_;iaRG,MtrSI",'a,LrASIF�pµlfrosnry 1.
.,.._ ..„
A
X
ParticiP ant 6 Legal Liabili by
10,000
y
SIBML00321-211
07/01/2021
07/01/2022 PERSONAL &ADV INJURY
$ 1,000,00._
GEN
' AGGREGATE APPLIES .
GENEA
$ 3,000,000
- 1
PRO-
POLICY❑JECTO
UC
PRODUCT
$ 3000 000
�(
OTHER; Per Region (25M Pol Agg)
�
$
AUTOMOBILE
LIABILITY
COMBINED SlN57 L MIf
$
ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
NJURY (Per; c oden[)I
....
$
AUTOS ONLY ,,,,, ,, AUTOS
�
HIRED NON -OWNED
...bbb
T DAMAGE
---
}
,.-,,,
AUTOS ONLY .......� AUTOS ONLY
Pcr ac
UMBRELLA IAB X OCCUR
RRENCE
$ 3,000,000, 000
A
X
CLAIMS -MADE;
EXCESS �0
SL8EX00267-211
07/01/2021
07/01/2022
AGGREEGAT
3 ,000,000
-
RETENTION $
$
WORKERS COMPENSATION
PER OTH
I
1 ER
AND EMPLOYERS' Y/N
—,
ANY ROPRIETOR/PARTBNER/EXECUTIVE
ELEACHACCI DENT
$
'", '"""' ....... -----
OFFICER/MEMBE R EXCLUDED?
N/A
Mandatory in NH
(Mandatory )
EµL,DISEASE_ EAEMPLOYEE
..... ....-- --.......,.
$..................................._.. ,
...$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E L. DISEASE -POLICY LIMIT
$
B
Excess Liability - $1M xs $314
18EX2268
07/01/2021
07/01/2022
Each Occurrence
$1,000,000
C
Aggregate
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Med Pay applies only to spectators at an AYSO Event. General Aggregate Limit Applies on a per Region basis.
Certificate Holder is an Additional Insured as respects AYSO sanctioned events only, and where endorsement is attached
and required by contract.
SEE ATTACHED
k,ttl.I.ICIF-AIC MULUCR ve+nVGLLf111V1�
The City of El Segundo, its officers, officials
employees, agents, and volunteers
350 Main St
E1 Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
U 1Vt$tf-ZU1b AUUKU GUKfUKAI IUN. All rlgnis reserveo.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SR ID: 21277487 BATCH: 2150000
AGENCY CUSTOMER ID:
ADDITIONAL REMARKS SCHEDULE Page 2 of 2
+w.�..
AGENCY NAMED INSURED
Willis Towers Watson Southeast, Inc„. American Youth Soccer Organization - AYSO Region 92
�19700 S. Vermont Avenue
POLICY NUMBER Suite 103
See Page 1 Torrance, CA 90502
CARRIER
See Page 1
NAIC CODE
g EFFECTIVE DATE: _ g
See Page 1 See Page 1
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
.... .......................
*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.
INSURER AFFORDING COVERAGE: Everest National Insurance Company NAIC#: 10120
POLICY NUMBER: S18ML00321-211 EFF DATE: 07/01/2021 EXP DATE: 07/01/2022
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Abuse & Molestation Each Occurrence $1,000,000
Aggregate $2,000,000
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SR ID: 21277487 BATCH:2150000 CERT: W21475B57
POLICY NUMBER: S18ML00321-211
COMMERCIAL GENERAL LIABILITY
ECG 20 600 05 09
THIS ENDORSEMENT CHANGES THE COVERAGE PART. PLEASE READ IT CAREFULLY.
! • a • "
• :1:4 •
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
AYSO Region 92
To: Shawn Green
From: Shad McFadden, AYSO 92, Regional Commissioner
CC: Monse Palacios, 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:
C __) 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 #
CfD
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
e
immediately
mmediat ly complywitht provisions or the agreement will automatically become void. 3/3/2
' Date
Print Name
�iad a en
Agreement for: Agreement #4814B
Dated: 3/29/21
Reviewed by: J L