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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