PROOF OF INSURANCE (2022) CLOSEDDATE (MMIDD/YYYY)
ACORD- CERTIFICATE OF LIABILITY INSURANCE 12/18/2020
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{les) must have ADDITIONAL INSURED prolusions 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 ricahts to the certificate holder in lieu of such endorsementtsi.
K&K INSURANCE GROUP, INC.
&iiYMIAU4 Cheryl Pettibone
NAME.800-736r7350
1712 MAGNAVOX WAY
847 853�a73
�.X
PO BOX 2338
t ��. �l , _ ........m ..... AMC,I�..._w.r_.ww.
FORT WAYNE IN 46601
ADDRESS Cheryl.Pettibone@kandklnsurence.com
INSURED
INSURERS AFFORDIN'GCKYV �,��� NAIC 9MEMBER
NO:
INSURER A. Nationwide Mutual Insurance Company 2378 y 7
� I'
a Nationwide Life eI1389
Insurance company
EL SEGUNDO BABE RUTH LEAGUE
_e+su_RER
INSURER C ............_ ....
DBA: El Segundo Babe Ruth
ti S-iTk lt D
750 Sierra Street
NSURER -
El Segundo, CA, 90245
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.
INISR ITRm TYPE OF INSURANCE Iha'SO WYD POLICY NUMBER
LIMITS
woolY'YYY IA�Ii/1(YYPOLICYEFF POLICY P Y�.'a
--
X COMMERCIAL GENERALLLLIABILITY
__..__...................
EACH OCCURRENCE �$2,000,000
/{ ..CLAIMS -MADE X IOCCUR
$ 300O000—.......
O12:01
Y RPG0000031509700
121011 AM AM MEDIEXP(A one ,000
12:01 AM (Any person) $ 5
m W�
�PERSONAL&ADV INJURY ` $2,000,000
..................._._..._.._.m,....._ _� _..
GEN'L AGGREGATE LIMIT APPLIES PER:
......�....w._... ...... ......... .....,..._......._._.
GENERAL AGGREGATE $5,000,000
POLICY 0 PROJECT 17 LOC.
_ PRODUCTSCOMP/OP AGG $2,000,000
OTHER:
PARTICIPANT LEGAL LIABILITY $2,000,000
AUTOMOBILE LIABILITY
to u'aSaN'Er'r IN LI";LGfi`�IT
$1,000.000
�E.r ArrrrdorJ,u ., .
ANY AUTO
BODILY INJURY (Per person)
A OWNED SCHEDULED RPG0000031509700
_en -...�--m----,
02/01/2021 02/01/2022 BODILY INJURY (Per accident)
12:01 AM
X. AUTOS ONLY x,,,,, AUTOS
HIRED NON -OWNED
12:01 AM
AUTOS ONLY „X AUTOS ONLY
gf°mf ¢6dndidarral
UMBRELLA LIAR I# OCCUR
EACH OCCURRENCE
EXCESS LIAB CLAIMS -MADE
AGGREGATE
DED I RETENTION
WORKERS COMPENSATION YIN
:STATUTE OTHFJi
AND EMPLOYERS" LMILtrY
ANY PRO:PRIETORPARTN R XECUTIVE
-® .
E.L. EACH ACCIDENT
OFFICERINIEMBER EXCLUDED? NIA.
-_... „— --- ............----
PUMandalory in IN
E.L. DISEASE -E A EMPLOYEE
as, dovzfta under
SCRIPT1ON OF OPERATIONS below
.......__.. ,.,.,.,.,.,.
E.L. DISEASE- POLICY LIMIT
"
02/01/2021 02/01I2022 'Excess Medical $250,000
B PARTICIPANT ACCIDENT BAXOD00031509600
12:01 AM 12:01 AM -�
AD&D
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If morespace is required)
THE CERTIFICATE HOLDER 15 AN ADDITIONAL INSURED, BUT SOLELY WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED.
Owner, manager or lessor of the premises where you conduct practices orgames
SEXUAL ABUSFJMOLESTATION: $1,000,000 PER OCCURRENCE/52,000,000 AGGREGATE
CERTIFICATE HOLDER
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.
City of EI Segundo
AUTHORIZED REPRESENTATIVE
350Main Street
IJ Segundo, CA 90245
ACORD 25 (2016103) m 1988-2015 ACORD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: RPG-315097-00 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
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 El Segundo its officers, officials, employees, agents and volunteers
350 Main Street
El Segundo, CA 90245
RE: El Segundo Babe Ruth League
Information required to complete this Schedule, if not
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury'
caused, in whole or in part, by your acts or
omissions or the acts or omissions of those acting
on your behalf:
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 agreement to
provide for such additional insured.
be shown in the Declarations.
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or 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 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
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.
1 affirm under penalty of pedury under the laws of California one of the following declarations:
(� 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 #
( # 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
immediately
�y comply with thas p rv�si�� s ors agreement will automatically become void.
Signature eof Applicant
Date -
Z / 21 7
Print Name P2 m F -°
Agreement for:
Dated: 9-23-21
Reviewed by: