PROOF OF INSURANCE (2024) CLOSEDACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
10/23/2023
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).
PRODUCER CO ACT Lauren Kachadarian
NAME.:
PHICO FAX
ESP Insurance Brokerage, LLC A'c Ncw (877) 670-2377 C Nw, l
306 Main Street E-MATL lauren.kachadorian@espspecialty.com
ADDRESS:.
INSURER(S) AFFORDING COVERAGE NAIC #
Worcester MA 01608 INSURERA: LIO Insurance Company 40550
INSURED INSURER B: Scottsdale Insurance Company 41297
International Pickleball Teaching Professional Association (IPTPA) INSURER C
2 Lyngby Court INSURER D;
INSURER E :
Riverwoods IL 60015 INSURER F
COVERAGES CERTIFICATE NUMBER: CL2362626039 REVISION NUMBER:
THIS
IS TO CERTIFYTHAT 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.
ILTR
TYPE OF INSURANCE
INSD
D
WV.
POLICY NUMBER
PO&,.IC'iEFF
MMpODF"/YYY)
PO" YEXP
_(MRfiliiDIYYYY.
LIMITS
....
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 2,000,000
AM N 100,000
PREMISES Ea pccu�renre $
CLAIMS -MADE � OCCUR
MED EXP (Any one person)
$ 5,000
X Participant Legal
PERSONAL BADVINJURY
$ 1,000,000
A
Y
L101100000283
07/01/2023
07/01/2024
GENERALAGGREGATE
$ 5,000,000
�GEN'L
AGGREGATE LIMITAPPLIES PER:
POLICY PRO.LOC
JECT El
PRODUCTS - COMP/OP AGG
$ 2,000,000
__
Abuse/Molestation
s $1M/$2M
OTHER:
AUTOMOBILE
LIABILITY
Cnrc ED,"`'Y1NGL�E LAMI°tl
EaacpaderwC' «wawa
$ 1,000,000
'.. ANYAUTO
BODILY INJURY (Per person)
$
A
OWNED SCHEDULED
L101100000283
07/01/2023
07/01/2024
'... BODILY INJURY (Per accident)
$
IX
AUTOS ONLY AUTOS
HIRED NON -OWNED
1�5
AUTOS ONLY AUTOS ONLY
--
UMBRELLA LIAR
I XJ
OCCUR
EACH OCCURRENCE
$ 1,000,000
B
X
EXCESS LIAB
CLAIMS -MADE
CXS4003588
07/01/2023
07/01/2024
AGGREGATE
$ 1,000,000
DED RETENTION $
$
WORKERS COMPENSATION
_ PER OTH-
STATUTE ER,
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNERIEXECUTIVE r----1
N I A
E.L. EACH ACCIDENT
$
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
E..L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT
$
Accident Health - Coaches -(A) Accident
A
Health Youth (B) PAYO-66009-2
LI01100000284
07/01/2023
07I01I2024
Maximum
$25,000
Number of Lives (B)
$500
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Coverage is Provided with respects to the pickleball certification process and the pickleball instruction provided and organized by certified member
teachers.
COACH: Nathan Staso
Additional Name Insured: El Segundo Parks and Rec
Address: 401 Sheldon Street, El Segundo, CA
CERTIFICATE MOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
El Segundo Parks and Rec
ACCORDANCE WITH THE POLICY PROVISIONS.
401 Sheldon Street
AUTHORIZED REPRESENTATIVE
ElSegundo CA 90245
sir
U 1SUB-ZU15 AGUKU GUKYUKAI JUN. Au rignis reservea.
ACORD 25 (2016/03) 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)9 ,
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
V firm under penalty of perjury under the laws of California one of the following declarations:
�p 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 Se
Policy No.
16 1 have and will maintain workers„ com ens ;
p anon 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 #
�51 certify that, in the performance of the work set forth in the agreement
g Bement 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 12visions o the agreement will automatically become void.
Signature of Applicant Date
Print Name
Agreement for:
Dated
Reviewed by: