PROOF OF INSURANCE (2022) CLOSED (2)wCERTIFICATE OF LIABILITY INSURANCE
DATE fMMfCNCVYY'Y'Yf,
16ji812021
THIS CERTIFICATE RS I SUEDA a -A MATTER OiF IINFORMATION Oi'HLYAN DCONFER S NO RIGHTS UH^O'Fl THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOE. NOT A,FFIIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES
B,ELOW. THISCERTIFICATE 'EIF IINSUReANCEDOE S NOT CON STITUTEACONTRACT BETWEEN THE IS SUING IN aURER (SS , AUTHORIZED
RE.F'RESENTATIVE.ORPRODUCER, AND, THE CERTIFICATE Hl
IMPORTANT: If the certificate Milder is an ADDITIONAL IINSURED, thie FNOIuey Gies} must have ADDITIONAL IN SURFED, pro'VRsiO,ms or be
endorsed. If SUBROGATION IS WAIVED, subjie,ctto, the termsand clonditRO,msoflthie poduey, certalilm poll, ijes may regMre an endorsement. A
state, ientlOn1tlhiscertific:ate,inotconf�errightsto,thec,ertifi ate,IhoideriimIlReuuofsuch e,mdorse, ent(s•).
P'R:ODUCE:R,
CONTACT
R,PE Bolling c
NAME:
EOO LrEl PairlL
PHORE,
FAX
Whippany, NJ 10'7'H1
IMC„RD Emtp: '-445-5311
Imc Ho.p:'R73-9s29-047A
FHON:NE: 1-8,00,..445-,53r11 FAX: 372-921-8474
E-IWM4zWL.
ADDRESS:
INSURER,i AF'FOR BING COVERAO,E
NAIO #
III14SURERA IMarkel Insurance company
3 gl:;?-101
IN SU RE:10
IIIPd SURER E:
USA Softball and Members of USA Softball of SoCal Indiv Reg
PrOCg'raim
uINISURERC:
11111SURER W:
Mike SCIILIck Krlst.l Allen
11111 SURERIE:
PO Box 6028
Oceanside„ CA 92052
u l RERF:
COVERAGES HOLI YCHAR+GENUMBER: IIR0202174551 REV] SiOR NU M BER,:
THIS IS TO CERTIFY THAT THE: P'OLICIEE OF' IN SURAN>VCE LISTE:DO EELC'r,4d HAVE BEEN ISSUED TO THE: IN SURER, NAMSD AECVE FOR, THE POLICY PERIOD INDICATE:C.
N^VOT+y"ITH'ST P4DINCC,AliY RE UIRE:IwVE:N+VT, TER OR CONDITION OF ANY CONTRACT OR OTHER DO—CUVE:N+VTWITH RESPECT TO, WHICH THIS C:E:RTIIFICATE; MAY HE ISSUE:D
CR, IAAY PERTAIN, THE IN SUR.ANC:E; AFFORDED BY THE POLIOIES CESC.RIEEC HERE IN 15 EUELECTTO,ALL THE TERVS, EXC-LUSIONd'S Ali COHOITIONS OAFSUCH
POLICIES. LIVITE SHOM MAY HAVE EEEN4 REDUCED BY PAID CLAWS.
IIH SR
LTR
TYPE OF IIHEURANCE:
ADDL
HSR
'SUER
'WiPID
POLICY NUMBEFY
POLUIC'Y IEFF
�KWDDIYYYYI
IPIDLIIICYIE:;1P
iffWDYYYYY1,
LIMITS
GENERAL
LIABILITY
x
EACH CICRRE" IE
5E.000.000
ix
LiAV 'E7fPRE 71ED
PRIF :SEI� Eac..u�rKOE-;
E1.00�0.0�0�0
A
C0Vll,!ER�IAL GENERAL LIADLITY
OLAI1dS-HAD E OOCUR,
3f'OE.A.HE:�3e0OtE:S
"LCOC1
1 �,fiL�,
Urr��LXrN �'r'dcnw rtsain;
E'10,000'"'
Pairdcipanta LIab
"'NV m-pairticipants only
PE FKNkL &KIP N URY
E2,.000,000
W�.AS° 5• FE GATE.
r5'.'"�7rJ.7rJx}
CaEN
'L..R' SGRE:Cs�c"TE: LRAIT.APPLIES PER .:
P'O'L,1'CY P'RC'- L,O'C,
L E:CT Ix
Sxx.wall
S-xuall
+ bLsa & Volestation L,liati psa
AbLse 9 Vollaslatbn sgs1.L
o,-cufrmnse. 5'e„+:0.
IIm1t 52000,000
0. pJ=CCU
ryRf.N 7 a' a 'I�
52.000.000
5
AUTOMOBILE',
LIABILITY
CCDNEIE IS,MSLE',LW,7T Faamlbent.�
F
Sx Ya Y tEe>r
E
,Alit ,AUTO
BcYa1 Y{per
E
ALL OWNED SC.HErU,LEr
AUTOS ,AUTOS
NViONt-Oo,AtNVE:OJ
C
HIREAAUTOS,AUTOS
rpcoidenPFRTY of Iw C'E
per aew.idarR,
E
E
UIIJB:RELLA LIAR XCUR,
EA HCmC" RRENIZE',
EXCESS LIAB CLA1,AS-
A SRE ATE
CEC RETENTION ':5
WORKERS COMP'ENS,ATGO�N
,AND EMPLOYERS' LIABILITY
IPT R STA,r'LITE
CTH-
E'R�.
E L EACHA µlDENIT'
Ar«'r I R:r. R c °aARTr E� E E LiTr E', Y' r H
It L D15EA5F Ir,AI VPP IYE'E
E
D GJFFIA>E MEERI XCt. U DEEP
NJ f A
(Mandatory in NH) �
';-, esl. desar14be unirder LIES "RPTN,ON1 ,DF
E L C�75E;Iw5E I.H 7u'Y �vGT'
'
CBPE:RAT I' CN:51'5'e-:I01dP
OTHER
BE:SiCRIP'TIONd OF OPE'RATION Si f LOCATIONI:Sl f VE'HPC.LES IAttarchtACORD tot Additional Rmm:arks Sihediuls, if im ore s,pacs isrsquiraz
COVE',RA^GE', UNDER: TH15 POLICY SHALL APPLY TO, LIABILITYOF' THE INSURE',CN AIR 15dNJG OUTOF' THE', ACNPIIINISTRATIONI, P'LAYOR. PRACTICE OF AMATEUR SOFTBALLJBAS:EBALL,
BUT ONJLY FOR INCIDENT Sl INVOLO'INGi B�OCNILY INLJURY, PERSONAL INTURYOR PROPERTY DA1UGE. C:E',RTIF'ICATE HOLDERIS HAIWIIECNASlAN ADDITIO^JAL I 5URED. THIS
C-E',RTIF'ICATE', IS 15SUEDONI BE',HALF' OF: E',L SEOUNICaOall RLS SOFTBALL
CERTIFICATE; HOLDER'. CA,NCELLATRON
City o£) 1Sep undo
SHOULD ANY OF THE. ABOVE DESCRIBED POLICIES BE. CANCELLED
3'r,II Main St.
BEFORE THE E:xPl11RA7I(O,N [DATE; THEREOF, NOTICE; WILL BE. DELIVERED IN
El Seg1mdo AL'9 fy'45
ACCORDANCE WITH THE POLICY PRO [SIGNS.
AUTHORIZED RE,P'RE,SE,NTATIVE,
@ 1 E B,2015 ACtO,R,C COR,PCDR:,ATIO,I14. All irigh'ts herei
ArC',fO�R,C 25 l 01&03; ThE: A.,CORD naniE anb 1-cggci arrE. irEgi5tEarEd nnairLa crf A,00, �RD
POLICY NUMBER: 3�602AKMG691 COKIMERCIALGENERAL 1-14.BILITl'
POLICY DATES: S,1112021 - 9111/2022 Do 20 26 04 1 a
'THIS ENDORSEMENTICHANGESTHE POLICY. PLEASE READ ITICAREFULLY.
ADDITIONAL INSURED - ICE IESIGNATED
PERSON OR ORGANIZATION
This enclorsernent imodifies insurance provided under the following:
DNA I M A ZIN M IIIIIIEM41 1 :111.1410 1 F11 QI I I I VAMMAZIFIRIM :711 2A I I
SCHEDULE
Name of Additional Insured Person(s) Or Organization(s):
City of El Segundo,
Information Feq u i red to, c orn plete, this Sc h ed u le, if not s h own a bave, wi I I be shown in the Declarations.
A. Section 11 -Who Is An lInsured is amended to include as an B. With respecet to the insurance afforded to these additional
additional insured the person(s) or organization(s) shown in insureds, the following is added to Section 11111 - Lirni,ts Df.
the Schedule, but only with respect to liability for lbodily injury"', lins,ur,ance,:
"property injury"' or personal and advertising injury caused, in If coverage provided to the additional insured is required by
'whole or in part, lby Your ads or omissions or the acts or a contract or agreement, the most ,we,will pay on lbehalf of
omissions of those acting on your lbehalf. the additional insured is the aMOU11t Of i11SUrance,
1. In the performance Of Your ongoing operations; or
2. In connection with Your premises owned lby or rented to
you.
However:
1. The insurance afforded to Such additional insured only
applies to the extent permitted lby law, and
2. If coverage provided to the 3dc11tiOI13I 111SUred is
required lby a contrast or agreement, the insurance
afforded to such additional irl S U re dwi I I not Ilse b ro a de -
than that,which you are required lby the contrast or
agreement to provide for Such 3dditI01131 IrISUred..
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 04 13 Copyright, Insurance Services Office, Inc.,, 20,12 Page 2 of 2
To: City of El Segundo
RE: Auto Insurance
3/7/2021
JL
This letter verifies that the El Segundo Girls Softball Organization does not own or operate any street
legal vehicles. We have no need to carry Auto Insurance.
Please feel free to contact me if you have further questions on this matter.
Ian Wilson
President ESGS
310-702-1441
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO.SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPL&EFt 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.
J affirm under ia&MO of Perjury urdler the laws of cambrnia one of the b0owirrg t=s: _
(_) 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.
LJ 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 #
( I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
m) loy 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
y will automatically become void.
Signature of Applicant Date
the agreement
immediately comply with prow
Print Name
Agreementicr ,.
Dated: 04-13-2021,�...._.,w.
i3O
rr y r�IPy sin a ny � el r l u
C3NtnJ PBII.aCiCyuCElScgiauda,o CrpiePl'inancial
Reviewed by.as-e
��
CCPf <r�„„'q�1VL./Y11YNdC'w1X," e�+,uvur�'�o-w�o,. c=US
C�NG^�Cp2i tN77i 1d Tkd: 0-OP Q[I