The URL can be used to link to this page

PROOF OF INSURANCE (2024) CLOSEDSOCCS1 OIL ID: A4C4C>R DATE (e1M1DDIYYYYI CERTIFICATE OF LIABILITY INSURANCE 0210912024. 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 ADDMONAL 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 endorsememM,. PRODUCER RPS Bollinger Sports & Leisure PO Box 1322 Morristown. NJ 07960 David Campanello 'Markel Insurance INSURED nne^s Edgy Sports Training seas, "Pleasantf`xt COVERA S CE TIFICATE NUMBER., RFAARION N S1B'ER: 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- TER161 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. NISR TYPE OF 11SURANCE ADDL SUSR POLICY NUMBER POLICY EFF....POLICY EXPIIS LIMITS A X coumERcwLc,EwwLuasnm EACH 1.000,000 CLAIMS -MADE [K OCCUR X X 193(I,.3 111051'2023 1110512024 n,; IS 100,000 Ire X incl Participants MED EXP i are perpnl 13 510 A X Sexual Abuse1MOl SIMILL1S2ML.L 11105/2023 1110512024 &ADV INJURY I „000106 GENLAGGEGA718pr'VTAPPLIESPER A AGCAEGATE 3,000,0 0 POLICY ❑ aC ❑ LOC 1.000,000 PRODUCTS - ",'OP AGG CTH OIdEBPwE $44uE uvrr AUTOMOBILE LIABILITY " ° r ANY AUTO BODILYINJURY6fw I S , ��pp��ppONLY ]� �D BODILY INJURY i er amdStY S AL7TO.;ONLY AfW � eup7 �3 UMBRELLA UAB OCCUR CH OCCI RRENC EXCESS UAS CLAIMSMADE AGGREGA DIED RE E'C^IT*NS WORKERS COMPENSATION YIN ANYPROPRI.E ORrJARTNEEXCLUOED�CUTIVE ❑ NIA E EACH.ACCIDENT AND EMPLOYERS* LIABILITYty wn I EL DISEASE - EA EMPLOYEE S under i IAi OF OPERATIONS below E L DISEASE - POLICY LINTCCtdent I r ION nsurance 102501-16 lit U23 1110 120 4 1VAed INax: 25,00 Full Excess Ded: 500 I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Admtlonal Remarte SChedule, maybe attached R more apace Is requIred) Certificate holder Is included as an additional insured, Coverage is rovided under the a policies only for s onsored1supervised activities of he named insured Tor which a premiurNas been hard. Waiver of Subrogation applies. This Insurance is ,Primary and non-contributory With any other insurance. CERTIFICATE HOLDER CANCELLATION CITYELS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED BSI The City Of EIta � rtS ACCORDANCE WITH THE POLICY PROVISIONS. officers, officials, e-mp byees agents and volunteers AUTHORIZED REPRESENTATIVE 350 Main St El Segundo, CA 90245 ACORD 25 (2016103) O 1988-2015 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: (_) 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. ( x) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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: 76 WEG AZ6AMU Carrier The Hartford Name of Agent Policy Number Expiration Date 9/26/24 Phone # 877 287-1312. Cx ) 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 1 must immediately 9 provisions or the a reement will automatically become void, Signature comply Dateof Applicant plicantith those 2/2/2024 Print Name Mitchell Goldberg Agreement for: Dated: Reviewed by: