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PROOF OF INSURANCE (2022) CLOSEDY ACOR CERTIFICATE OF LIABILITY INSURANCE DATE"m' 010021 THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREIR(SL AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the cerfificate holder is an ADDRIONAL INSURED, the pollcy(Jes) must have additional insured provision or be endorsed. It SUBROGATICIN 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 tat such endorsement(s), PRODUCER 00KrACT RPS W Ming Pmohz 7�= x 13FIX PO Bo22 (Ar-imm":800446-531111 Noj� 973-921-8474 Monistawn, NJ 07900 E-KAJL PRONE: 1-800446-5311 FAX: 973-9214474 ADDIM35: IN SURERJ AFFORDING COVERAGE NAIL X INSUIUM A- Markel Insurance Coimpay M70 INSURED INSwWRB: US Lacrosse, Inc. MISILINIMC: 2 loveton Circle Sparkrs-N0 21152 Re: FA Segwido Lacrosse e. 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. N07WITHSTANDING 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, EKOLUSIONS AND CONDITIONS OF SUCH POLICES LIUITS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS WSR TYPE OF INSURANCE — I — POLICY NUMBER LIMITS � LTR WSR Mrm (NMDONY") fWNn0ffM1I A GENERAL LIABILITY COUVERCIAL GENERAL LIABIL17Y X GLAIMS4AADE f7XOCCUR x 8502AI-M'1369 G110112021 OVOIA2022 DMAAGE TO f-EINTED NmD EXP gip' WE X Participants Liab GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F PRO- LOC :1 JECT Sewal SemW Abqze 9 WL-statimi LA* W. Abwse & Aestation Ag,2t--pte px S1.,,NXI4A0 fffwk: $2, ,DIM PERSCUAL & ADV 04MRY � GDACC-81EGATE PRODOM - 00M10P AC-r� -S AUTOMOBILE LIABILITY COVSiNEa WC4E LMT Ma 3=kMM ANY AUTO BCOXY 0,1411,wr ME nPlayn 50Dxy NAAY Mar wwam ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED PROFERTY DAMAGE S AUTCS UMBRELLA LIAR I v JOCCUR x At GATE... A X �A IA UAW - S Lu 4602AH221370 O11O1r2021 OV0112022 DFD [—] RETENTIVN S, 'WORKERS COMPENSATION YIN AND EM PLOYERS' LIABILITY AMY PROPRIM70%. PVi T N: R NfA per allLW El EAQIACCEAN7 S i!.'. L C95EASE - EA P.-ANILCIML S 0FFKX%1AEPAS9-4UGLLUED? (Mandatory in NH) r EL OKEAAR'. - RMCY LAC' OPERATIPONS DWR A [Accident Medical 4102AH025220 Olffil Q021 D1ffi1J2022 Limit: 3100,000 r-atastrophic Ace 4102AH305882 01101120 1AWdem CatestTeph I c Limit: 91,00,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional ReffnarksSchectule. if more space is required) Coverage applies only toleanisleagues comprised of 100% US Lacrosse players And coaches d�uring scheduled & supervised lacrosse activites. Certificate Holder Is named "Additional Insured " with respect to, El Segundo Lacrosse, CERTIFICATE HOLDER CANCELLATION City of El Segundo, its officers, officials, employees, agents and volunteers 350'Nlain Street F1 Segundo. CA 90245 ACORD2E)(,.M16-Ti3) The ACORD name and 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 33=1� I certify that the team, league, or event on whose behalf I am requesting this certificate mandates 100% membership in US Lacrosse for all players and coaches. In addition, I have verified our team's or league's events roster and all players and coaches are currently registered members of US Lacrosse. I certify that this is true and I understand that liability coverage is only extended to our team, league, or event if all players and coaches are current members of US Lacrosse. Further, I acknowledge by clicking on this box that liability claims may be denied for coverage if our team/league or event does not have 100% registered players and coaches with US Lacrosse. Name: Steven Wood Organization: El Segundo Lacrosse Date: 01 /20/2021 POLICY INUMBER: 3502AH221:369 COMMERCIAL GENERAL LIABILITY IUS ILacrosse, Inc. 11112020A/1/202el CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PANT SCHEDULE Name of Additional Insured Person(s) or Organization(s) City of El Segundo 401 Shelton St. El Segundo, CA 90245 0tx10 The City of Ell Segundo, its officers, officials, employees, agents and voluM*ers are named as additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 part, by your ads or omissions or the acts or omissions of those acting on your behalf: 1. In the perforamce of your ongoing operations; or 2. In connection with your premises owned by or rented by you. However. 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If the coverage provided to the additional insured is required by a contract or agreement, the insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurancee afforded to these additional insureds, the following is added to Section III — Llmlts of Insurance: If coverage provided to the additional insured is required by 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 fimits of Insurance shown in the Declarations. CIS 20 26 04 13 Copyright Insurance Services Office, Inc_ 2012 Page 1 of 1 POLICY NUMBER: 8502AH221369 COMMERCIAL GENERAL LIABILITY U.S. Lacrosse, Inc. Policy Dates: 01/01/21-01/01/22 CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART, SCHEDULE 1. Designation of Premises (Part Leased to You): Athletic Facility 2. Name of Person or Organization (Additional Insured): The City of El Segundo, its officers, officials, employees, agents and volunteers 350 Main Street El Segundo, CA 90245 Issued on behalf of: El Segundo Lacrosse Events to take place January 20, 2021 - January 01, 2022. 3, Additional Premium: NIL (If no entry appears above, the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS INSURED (Section ll) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any "occurence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 El Segundo Lacrosse March 1, 2021 To Whom It May Concern, This is to attest that El Segundo Youth Lacrosse, both the boys and girls divisions, do not use automobiles at any time in the operation of our league. Therefore, we do not carry any automobile insurance. If you have questions, please contact me. Brooks Roscoe Executive Director El Segundo Lacrosse ir�C�oks,i' is e c. rnaifcom 310 227 5112 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: L_) 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 # WI 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 comply with those provisions or the agreement will automatically become void. Signature of Applicant A7� DA%1/21 Brooks Roscoe Print Name �S,ff— Agreement for, PAO-D 0 �� A 9/23/21 Dated: Reviewed by: