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PROOF OF INSURANCE (2022) CLOSED
MIDD AC40R"' CERTIFICATE OF LIABILITY INSURANCE DATE(09(07/20 ' 7(2021 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 Karen Sumner NAME; .................. Correll Insurance Group of Hilton Head PHONE (843) 785-7733 FAX PO Box 6869 E-MAIL, Anhcccc„ Karen@correllhhi.com INSURER(S) AFFORDING COVERAGE NAIC # Hilton Head Island SC 29938 INSURER A: Philadelphia Indemnity 18058 INSURED INSURER B Professional Tennis Registry, Inc.; Professional Pickleball Registry Inc. INSURERC: Professional Platform Tennis Inc,;, INSURER D P. O. Box 4739 INSURER E Hilton Head Island SC 29938 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2172931353 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSFi .�."� ............. ... .PUt_I Y__ ..... LTR TYPE OF INSURANCE !NSD y,/yD POLICY NUMBER '', MMIDDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 100,000 CLAIMS -MADE OCCUR PRFhhuS ES' Fa dsrewtcta __ __ $ MED EXP (Any one person) $ N/A A PHPK2307627 09/01/2021 09/01/2022 PERSONAL&ADV INJURY $ 1,000.000 GEN'LAGGREGATE LIMITAPPLIES PER: I GENERAL AGGREGATE $ 3,000.000 POLICY J'E46 LOC PRODUCTS - COMP/OPAGG $ 3,000.000 J $ OTHER: AUTOMOBILE LIABILITY COMBONED 5MG4...D LtBkit&T Eat �eccadenf $ ANYAUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED FROPERTYOAMAG'a. $ AUTOS ONLY AUTOS ONLY Pw acrr1pn X UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 5,000,000 A EXCESS LIAR PHUB779551 09/01/2021 09/01/2022 CLAIMS -MADE AGGREGATE 5,000,000 $ �........ DED /"4 RETENTION $ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E. L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ......................................................................_. (Mandatory in NH) E.L.. DISEASE., EA EMPLOYEE $ If yes, describe under "" _-"- "' ". """" DESCRIPTION OF OPERATIONS below E. L. DISEASE - POLICY LIMIT $ ._....... .................................................................................. ............................................... DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) ....................................... [Job #: 1575 Job Type: ] 84330 - Certificate Holder is listed as Additional Insured # 1575 with respect to Member #122863 - Cade Erickson , t CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of El Segundo, its officers, officials, employees, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN agents and volunteers ACCORDANCE WITH THE POLICY PROVISIONS. 3501 Main St El Segundo, CA 90425 AUTHORIZED REPRESENTATIVE even �'•�u>7+y,tf- ©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 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 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 CALIFORNIA EVIDENCE OF FINANCIAL RESPO S Name a-d Address of Insured MIC 25968' Pollcy No. )1 have and; will maintain workers' of the work for which the agreernont carrier and policy number are, Carrier Name of Agent, [z] I certify that, in the performan employ any person in any manner agree that, if I should become sut immediately comply with those prov Signature of Applicant Print Name Agreement for:_t Dated 4/ Reviewed by: i !................�;