PROOF OF INSURANCE (2024) CLOSED0 DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
��,.. 12I08I2023
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 Michele Reitz
NAME:
.......
r.
Correll Insurance Group of Hilton Head 1AVcA (843) 785-7733 Not,
PHON
E-NIAIL@correllhhi.com
PO Box 6869 erertirrr.cc, mreitr @
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Philadelphia Indemnity
18058
Hilton Head Island SC 29938
INSURED
INSURER B r..
INSURER C
Professional Tennis Registry, Inc.
Professional Pickleball Registry, Inc.
INSURER D:
Professional Platform Tennis Registry, Inc, R O. Box 4739
INSURER E :
INSURER F:
Hilton Head Island SC 29938
COVERAGES
CERTIFICATE
NUMBER: Master2023-2024
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
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.
'ILTR
TYPE OF INSURANCE
INSD'
WVD
POLICY NUMBER
MM PDM,rYY
MM/DD/YYYY
LIMITS
'" COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
100,000
CLAIMS -MADE � OCCUR
PREMISES Ea occurrence
$
MED EXP (Any one person)
Excluded
'.. $
A
PHPK2584296
09/01/2023
09/01/2024
PERSONAL & ADV INJURY
$ 11000,000
GENERALAGGREgATL
�wwww
$ 3,000,000
GEN'LAGGREGATELIMITAPPLIESPER:
^.
POLICY P'FdO LOC
JE�CT
PRODUCTS - COMP/OP AGG
.,.-.
$3,000,000
$
'.. OTHER:
LIABILITYD
SINGLE LRMIET
M INE.aLcou&no8)
KM
$
ANYAUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
HIRED NON -OWNED
�..e_......._..._._...
PROPERTYDAMAGE
$
AUTOS ONLY NAUTOS ONLY
Pse accident.
......
UMBRELLA LIAR OCCUR
..._.........
_
-'_____.
m
EACH OCCURRENCE
$ 5,000,000
AEXCESS�L,IIABCLAIMS-MADE
nX
PHUB875223
09/01/2023
09/01/2024
AGGREGATE
$ 5,000,000
DED X RETENTION $ 10,000
PAND
$
PER ER
STATUTERPROPRIETOR/PARTNER/EXECUTIVEN/AE
KERS COMPENSATION
EMPLOYERS' LIABILITY Y / N
L EACH ACCIDENT
$
CER/MEMBER EXCLUDED?
datory in NH) "" .
E.L. DISEASE - EA EMPLOYEE
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
[Job #: 2033 Job Type: ]
132885 - Certificate Holder is listed as Additional Insured # 2033 with respect to Member # 132885 - Penelope Finders , 401 Center Street , El Segundo CA
90245
CERTIFICATE HOLDER CANCELLATION
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 ACCORDANCE WITH THE POLICY PROVISIONS.
em ployees,agents, &Vol u nteers
AUTHORIZED REPRESENTATIVE
350 Main Street
EL SEGUNDO CA 90245
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Additional Named Insureds
Other Named Insureds
jProfessional. Tennis Registry Sezvices, Inc.
jProf-essional Spojrt.,.s Registi�y, lnc.
IL'adell Coaches Reqi.stry, Inc.
11'rofessionai. SiporLs Registry FOUTida�.:ian, Inc.
ISCT.UaSh C.'oaches Regastry 1nc,
11-'rof.essional Tennis Registry Founc.MtAori
OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
1S 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:
1 have a. w will i-naintain 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.
U 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 #
WI 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 prov' ns or the ree» rent will automatically become void.
Signature of Applicant '� Date 3 ZZ
Print Name
Agreement for:
Dated:
Reviewed by: �'