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PROOF OF INSURANCE (2023) CLOSEDACC CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/°°",YY' h 01/17/2023 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). PRODUCERCONTACT NAME: American Specialty Insurance & Risk Services, Inc. _ PHONE & NPn FAx Eta .. .. .........� gal �.�a . dba A.S.LR.S.I. Insurance Agency (CA License #OE72661) MAIL 4ppRp, ........ 7609 W. Jefferson Blvd., Suite 100 1 C, INSURER�Sj AFFORDING COVERAGE AI # N Fort Wayne IN 46804 .INSURED..�....................................................................................._....,.,_........____.............__.......____--- INSURER A: Arch Insurance Company 1 11 50 --__..........----...........---------,.,.,.,...............................................-____......................... INSURER B : National Association of Sports Officials (NASD) INSURER c : ---- _ ..........,.�..... 2017 Lathrop Avenue INSURER D: INSURER E : Racine WI 53405 INSURER F : COVERAGES CERTIFICATE NUMBER: 1002075513 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 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � �..-. �� , �..... .... -L __.EF -_. .- POLICY INSR ..... ADDL....JBi POLICY EFF POLICY EXP . __-- ._-- ......... T TYPE OF INSURANCE.._.. WVD POLIGX NUMBER.... M IDD n MWDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR .bA9MjEY�f kENT m ,PR f��E,�„�F.,�„p„cc�r{,gnce,�_ r._ ....... 1 000000 $,�„� ___ , _ MED EXP (And one person) Excluded � $_, �,-- _ A Y SBCGL0279605 08/01/2022 08/01/2023 PERSONAL & ADV INJURY $ 1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: LAGGREGATE GENERA ' $ 5,000,000 PR' LDC — _JECT u.. PRODUCTS-COMP/OPAGG 5_.,000,000POLICY $ O-tHrR. OFFICIAL $r AUTOMOBILE LIABILITY COMBINED SINGLE: LIMIT IEAµA) ... $ -.. ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED .................. .............._._. BODILY INJURY (Per accident) ..... $ AUTOS ONLY AUTOS ......... �,. .. HIRED NON-OWNEDIf�ROPERTYDAMAGE. $ AUTOS ONLY AUTOS ONLY .,„(,Pr'r acxllralp ________._ _— UMBRELLA LIAB LKI OCCUR EACH OCCURRENCE $ 5,000,000 _....._... A X — EXCESS .... m E 4 ....m ..GLAIMS-MAD SBFXS0044405 08/01/2022 08/01/2023 ,AGGREGATE $ Included .....................�. DED I RETENTION $ $ WORKERS COMPENSATION G PER GOT H- Y� ANYP OPRIETOR/PARTNE EXECUTIVE i E.L. EACH ACCIDENT OFFICR MEM EREXCLUDED? N / A -- -� (Mandatory B) E.L. DISEASE EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 Additional Remarks Schedule may be attached if more ace is required) ( � Y P 9 ) - Coverage applies to JOHN ZIELLO, 704 CAMINO REAL, REDONDO BEACH, CA 90277„ - The Certificate Holder shall be an Additional Insured, but only with respect to the operations of the Named Insured, and subject to the provisions and limitations of Form CG 2026 - Additional Insured - Designated Person or Organization, effective January 17, 2023. CERTIFICATE HOLDER CANCELLATION The City of El Sequndo 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: AC"R"- AnniTinkiAl RFMARKC -grwi= i 11 F AGENCY American Specialty Insurance & Risk Services, Inc. POLICY NUMBER SBCGL0279605 __........................................................... CARRIER. Arch Insurance Company NAMED INSURED National Association of Sports Officials (NASD) 2017 Lathrop Avenue NAIL CODE R_acin_e_,.WI 53405 11150 EFFECTIVE DATE: 08/01/2022 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: AC RD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE - Certificate #1002075513 Paae 1 of 1 - Unintentional Errors & Omissions, $100,000 each wrongful act/$100,000 Annual Aggregate per official/assignor - Other Named Insured: National Association of Sports Officials (NASD) & NASO-member officials, including officials enrolled by associations, contracted with NASD, but only while acting in their capacity as officials during sports events organized - Other Named Insured (cont'd): by a recognized sanctioning body or organized by another entity, where the rules of a recognized sanctioning body are followed, such as local Park Department or any formal organized association, and/or while attending seminars, conferences, and similar meetings designed to improve their officiating knowledge and skills and/or providing instruction to or evaluation of another official. - Other Named Insured (cont'd): LLC's that are created by an NASO member officials for the sole purpose of handling payments from officiating and assigning activities. - Other Named Insured (contd): It is further understood and agreed that NASO member officials and his/her respective LLC is considered to be one entity for the purposes of coverage throughout the policy and all amendatory endorsements. - The excess Aggregate Limit applies separately to each "official" insured under this policy. However, in the event of a suit by one or more plaintiffs against more than eight "officials", the Aggregate Limit will not apply separately to each "official", and a single aggregate limit of $20,000,000 will apply collectively to all individual "officials" covered under this policy. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 Name of Agent Policy Number Expiration Date Phone # I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not mploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should beco subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with ose rsic; jl pt+matically become void. Signature of Applicant Print Name Agreement for: Dated. , Reviewed by: � Date L21