No preview available
PROOF OF INSURANCE (2022) CLOSEDA C>R DATE (08/2021 CERTIFICATE OF LIABILITY INSURANCE 11/os/2o21 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 endorsemeril PRODUCER CONTACTKaren Sumner NAME: 5--....... �...................... Correll Insurance Group of Hilton Head PHiOAN (843) 785 7733 FAX unnlaFcctl'..-......_.._._........__.........................._&kf Nol. ............. ......M ...........��............. PO Box 6869 Karen@correllhhi com INSURER(S) AFFORDING COVERAGE NAIC # ............................................ Hilton Head Island SC 29938 INSURERA: Philadelphia Indemnity 18058 INSURED INSURER B ..............................................M .........- Professional Tennis Registry, Inc; Professional Pickleball Registry, Inc, INSURER C : Professional Platform Tennis Inc; INSURER D : P. O.. Box 4739 INSURER E : Hilton Head Island SC 29938 INSURER F: COVERAGES CERTIFICATE NUMBER- CL2172931353 REVISION Nl1MRFR- 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 CONTRACTOR 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, INSR POLICY E F POLICY EXP LTR TYPE OF INSURANCE IN P WVD POLICY NUMBER MMIDDNYYY MMIDDNYYY LIMITS X........ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X DAMAGEN 100,000 CLAIMS -MADE OCCUR PREMISES(Ea occurrence) S MED EXP (Any one person) S N/A A PHPK2307627 09/01/2021 09/01/2022 1,0o0,000 PERSONAL SADVINJURY $ GENERAL AGGREGATE S 3,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: , CI: LOC J 3,000,000POL.ICY s CRIER: AUTOMOBILE LIABILITY 'C0 MERNED gNG,E LIMIT S _(Ea 7+:ddeni1 )� ANYAUTO BODILY INJURY (Per person) S •' OWNED SCHEDULED BODILY INJURY (Per accident) 5 AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) 5 ._ ._m X UMBRELLA LAB X OCCUR _ ..... ......... EACH OCCURRENCE S 5 000 000 A EXCESS LIAB CLAIMS -MADE PHUB779551 09/01/2021 09/01/2022 AGGREGATE 5000,000 5 DED X RETENTIONS 10,000 �•••••. ..... $ WORKERS COMPENSATION ... �ERI{.... . AND EMPLOYERS' LIABILITY YIN .,;STATUTE.,, """" •""...... """"' ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED?El NIA •..............-.........__........................ ...........__.......__....,..� (Mandatory in NH) '.. E L DISEASE EA EMPLOYEE '.mmS If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT ''. S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) [Job #: 1625 Jab Type: ) 121915 - Certificate Holder is listed as Additional Insured # 1625 with respect to Member # 121915 - Connie Thrasher, 0W El Segundo CA 90245-2228 CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of El Segundo, its officers, officials, employees, ACCORDANCE WITH THE POLICY PROVISIONS. agents, & volunteers 3501 Main St AUTHORIZED REPRESENTATIVE ElSegundo CA 90425 e+h�.n �• umhU' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK2307627 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): The City of El Segundo, its officers, officials, agents, and volunteers. 3501 Main St. El Segundo, CA 90425 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 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. 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 04 13 © Insurance Services Office, Inc„ 2012 Page 1 of 1 71'* TRAVELERS California Automobile Insurance Identification Card The vehicle described below is covered by a liability policy .h...............................�.......'.....__........ tat meets California's insurance requirements, Year Make Model Vehicle umber (VIN) 2020 TOYOT 4RUNNER SR Agent Policy number Effective date Expiration date OCTF07 600590525 203 1 11/11/2021 05/11/2022 Insured NAIC 36137 CONNIE THRASHER Company: TRAVELERS COMMERCIAL INSURANCE COMPANY One Tower Square, Hartford, CT 06183 For policy questions and changes To report a claim FULLER INS AGENCY 24 hours x 365 days a year 909„597 9032 Go to Travelers.com or Call 1.800.252.4633 Keep this card in the vehicle at all times. See Reverse Side. Ad W- TRAVELERS California Automobile Insurance Identification Card The vehicle described below is covered a by _.......y policy , that .... meets California's liab..t'Ift ia's insurance requirements, Year Make Model Vehi .1e identiflcaflo number (VIN) 2020 TOYOT 4RUNNER SR Agent Policy number Effective date Expiration date OCTF07 600590525 203 1 11/11/2021 05/11/2022 Insured NAIC 36137 CONNIE THRASHER Company: TRAVELERS COMMERCIAL INSURANCE COMPANY One Tower Square, Hartford, CT 06183 For policy questions and changes To report a claim FULLER INS AGENCY 24 hours x 365 days a year 909.597.9032 Go to Travelers.com or Call 1.800.252, 4633 Present this card with your application for registration. See Reverse Side. 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: (___} 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. L} 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 # gi 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 agr ement wilt automatically become void Signature of Applicant ' r` Date i Print Name L' t�l n 1 L.K Agreement for: C c> t l l p Dated: ` I � -,,o - A Reviewed by: Hank Lu, Risk Manager