PROOF OF INSURANCE (2022) CLOSED0 (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INISURANCE
1723,2071
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 ils 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 conifer rights to the certificate holder iin lieu of such endorsement(s).
PRODUCER �_UNIAU
NAME: Cathcrinc Phaia
WeStCffl RCj'1LIhhC liom,inmcc Scivices 7I4.53(, FAX
jA/C,Na, Extj::05100 (A?C, No):
r-INAIL
19900 Hw"Llch Mvd ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIIC #
I hnitin,,ncm Beach CA 92648 INSURER A: SCOT'I SDALE INS CO 4 1297
INSURED INSURER B:
JLi,uar F,�,nms Acadcm)), LLC INSURER C:
401 Sh,aIchm SI INSURER D:
INSURER E �
El SCLHIdO CA 90745-411I3 INSURER F::
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER -
THIS IS TO CERTIFY THAT THE POLI01ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED, TO THE INSURED NAI'dIED ABOVE FOR THE POLICY PERIOD
IINDgCATED,. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR 'JAY PERTAIN, THE INSURANCE AFFORDED, BY THE POLI01ES DESCRIBED, HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICflES. LIMITS SHOWN IAAY HAVE BEEN REDUCED BY FAM, CLARdIS
MIR
LTR
TYPE OF INSURANCE
AIJUL
INSD
bWUVUDK
POLICY NUMBER
I A UILY t:FF
M IDDYYYYJ
Ly LA
(MUW 14D_y1YtY:AYY)
LIMITS
MERCIAL GENERAL UABILITY
EACH OCCURRENCE
$ 1 '1000,0010
PCLAIIYv1S-MADEF_X]OCCUR
DAIM�E TO RENTED
PREMISES, (Ea OCCLreince)
100,0010
MED EXP (Any oine person)
$ 5,000
PERSONAL & ADV INJURY
$ 1 '1000,0010
A
y
CPS7423491
09, 11 '2 021
01P I L 21022
_I
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$ 2,1000,0010
POLICY ETPERCOT- F-] LOLL'
PRODUCTS - COMROP AGG
$ 2,1000 0010
OTHER
$
AUTOMOBILE
LIAB11LTTY
accident)
$
—
_(Ea
BODILY INJURY (Per personP
$
ANY ALIT 0
'0�11NED SCHEDULED
4 TO'SONLY AUTOS,
—
BODILY INJURY (Per accident(
$
HIRED NON-01ANED
AUTOS ONLY AUTOS, ONLY
—
ler accident)
$
UMBRELLA Ll B
OCCUR
EACH OCCURRENCE
$
EXCESS LIAR
� CLAIIMS,-MADE
F,
AGGREGATE
$
DED I
I RETENTION
$
VWVO KIER S COMPENSATION
AND EMPLOYERS' LIABILITYSTATUTE YIN
i iEEL
El EACH ACCIDENT
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
BER EXCDED'?
OFFICERWEM EXCLUDED'?
El
NIA
El DISEASE - EA EMPLOYEE
$
(Mandatory in NHI)
If xes, describe under
� D SCRIPTICA OF OPERATIONS bp«ovv
El DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if gnore space is required)
ThOSe LISLKII W the itMired's operalions, Certificale II is rew"nized L"ys an addifionfl itMired in regard lo the Genend Liability T,q)hcy per the attL"Ched
GLS-477s,
,I hC 11)) o) LI squ I odou o ["I iec I s' o lic;iaalti auiglo Cs a Pc I �['' a I �d
olunwcls
401 Sh,,Ichm Acinx
1.1 SCLRfld0_ ('A'90245
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
rolk,t'6-4' P(40"
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and Ilogo are registered marks of ACORD
JII SCOTTSDALE INSURANCE COMPANY8
ATTACHED TO AND
ENDORSEMENT EFFECTIVE DATE
FORMING A PART OF
(12:01 A.M. STANDARD TIME
NAME D INSURED
AGENT NO.
POLICY NUMBER
jCPS7423491
109/11/2021
JJAGUAR TENNIS ACADEMY, LLC
104068
11111261 &2:4219101 ZMA T11:4 9 111 1111150112IT0,1101 **11211:11111:101 N 1411 114TRUIS SK-11911111 III WA
ADE)MONAL INSURED—IOWNERS, LESSEES OR CONTRACTORS
—
COMPLETED COMMERCIAL OPERATIONS
This eindorsement modifies linsuirance (provided undeir the folloWii
Naiii Of Additional Insured Persiori
Or Orgainizationi(s)
Commercial (Project Location And IDesclriptioln
Of Completed Commercial Operations
THE CITY OF EL SEGUNDO, ITS OFFICERS,
OFFICIALS, EMPLOYEES, AGENTS, AND
VOLUNTEERS UNITED STATES
RECREATION PARK
401 SHELDON STREET, EL SEGUNDO, CA
90245
�linfoirmation Iregluired to complete thins Schedule, if not showin 6bove, will be showin in the Il eclarafions.
A. Section II—Wfto Is An Ilnsluilred is aimended to iii as an addiftioi iii the persoi or or-
ganlizationii shown lien the Schedule, but only with respect to Ilialbillity for "bodfly lii or "'property
damage" caused, lien whote oir in Ipairt, Iby "'your work" at the comimei project location designated
and described in the Schedule of this endoirseiment performed for that addifional iilnslurled and iinciliuded
in the "products -completed operafions(hazard.,,
Howevei
11. The insluraii afforded to such addifional iinsuired only apphes to the extent Iperrmiltted Iby (law.
If coveirage proVided to the addifioinall insured is Irequlired Iby a cointract or agreement, the ii
ance afforded to such additional insured wiH not Ibe broader than that which you are required Iby
the contract oir agireeiment to proVide for siach addftioinall insured.
3. This iinsuirance does not apply to "bodfly infury" oir "'property daimage" arising from "your work" on,
in connection with or in any way relating to a "iresiideintial project."
includes Copyrighted mateiriall of ISO Properties, 11m, with iits permissiion,
Colpyright, ISO Properties, Inic, 21012
GILS-447s (2-15) Rage 1 of 2
iB, With respect to the )insurance afforded to these addiitlional iinsureds, the fclllowing its added to Sec-
tion Ill —Limits Of Insurance:
If coverage provided to the addiitlionall )insured its required by a contract or agreement, the most we vviilll
pay on behallf of the addiitlional iinsured its the amount of )insurance:
1. Required by the contract olr aglreelrmelnt; or
2. ,Available under the applicable Limits of Insurance shown in the Iaeclalrations; wNchevelr lis less.
"Thus endorsement shall) not )increase the alppliicablle Limits of Insurance shown iin the I eciarations.
For Ipulrposes of thus elndolrselrmelnt, the folllowing defilnitliolns apply:
"Reslidentliall (project" means any (project involving the olriglinal development olr olrigilnall colnstlructlioln, Irecon-
structlioln, (renovation or relrmodelling of olne or more slinglle-farmlily or rmultli-farnlily housing units, town-
houses, townlhormes, residential condclrmlinliulrms olr coolpelratives, duplexes, othelr structures converted into
colndormlinliulrms or any other type of domicile )intended for )individual) olr colllectlive residentiall owinelrshlip, and
shall) )include alll phases of the development, colnstlructlioln, recolnstlructioln, relnovatlioln or Iremodelling of all)
areas appurtenalnt to these structures, lincludling but not fiirmlited to land acqulislitioln, slite lirmlprcvelrmelnts, ex-
cavation or grading of (land, lutitities, driveways, wallkways, roadways, swii mrmling Ipoolls, retaliniing walls"
construction of any other structure, building, or cormrmon areas. "Residentliall (project" does not mean ""your
work" Iperformed iin connectiion with an apartment bundling" or ""your work" Iperfon-ned sollelfy on or in corm-
rmenclial space of "",rmiixed-use Ibulilldiings."
"Mixed -use Ibuilldliings" means structures and lirmlprcvelrmelnts thelreto, which contain (both Ireslidential ulnlits
and commercial space.
AUTHORIZED REPRESENTATIVE DATE
lrnchudes copyrighted mrnaroeriiall of ISO Properties, Ilnc., wiithi iirts permrniissbn.
Culpyriiglh t, IISC Properties, Ilimc., 21012
ILS-447s (2-15') Page 2 of 2
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 #
LX_) I 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 I
must immediately cornply with those provisions or the agreement will automatically become void.
Signature of Applicant Date
Agreement for:
Dated:
Reviewed by: