PROOF OF INSURANCE (2025)/11aC� DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 6/18/2024
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
NAME................ ... ,W.
PHONE
612-345 9683 _ c Ne)......... -
LIC#40558248 ,eOaeOeep
E-MAIL Player's Health Cover USA Inc. ADDcertiflcat s rr pda ersheaitfl com
RI5;.....y......,_,
I
718 Washington Ave North #402 IN AFFORDING NAIC#
.. ---
Minneapolis MN 55401 INSURERA State National Insurance Company Inc 12831
INSURE ..... ,. ... ..........-----........ ........ ........... ... .....................
HDI Global Specialty SE 41343
D ......... ........ .. .........
9 Fire Insurancom e Cpany m . s 21113
American Youth Soccer Organization In(suERc United States
19700 S. Vermont Avenue, Ste 103 INSURER-D ---__ ......... ..... .... ........... ,
...INSURER E • ...... ..................... �g
Torrance CA 90502 INSURER F
rnvGDAnG¢ CPDTIFII^_ATF NIIMRFR• IIA7f1R REVISION NUMBER: 3
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. ...
.- ..- ... . ........ ....... .., .. ................. ... ...POLIC'.....
EFF Pp64C'Y EXP ----- .......... .,.......,_ ...........-
1"JI4iC7FLt9Yttlitf --------
..IT..,. _ ......TYPE �MMMDfYYYY LIMITS
OFINSURANCE,.....
POLICY } MMMROV YY
WVDNUMBER
1
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1 OOO OOO .'.
t'AiA"s.�'E Pl9RENCr"t7 ---
CLAIMS -MADE �X."IOCCUR
PREMISES,(Eaocaurren„se)$1000000
....., ...
ny one persog)
5,000
A
Y
OVE-0001274-00
7/1 /2024
7/1 /2025
PERSONALA& ADv INJURY
$ 1 000 000
r, LIMITPPLIE
N'L AGGREGATE AS PER:
GREGATE
$ OO
PRO^
POLICY LOC
E � � JFCT �
PRODUCTS- COMP/OP AGG
$ .... 2,000,000
x OTHERi EVENT
i%�,i L%CL ��.B
$000,000
AUTOMOBILE
t
C'OMBINEDSINGLE LIMVr
1
I .._
$ 1,000,000
.. .,,.....u..
ANY AUTO
BODILY INJURY (Per person)
ILcpdx5JU'
BODILY
I $
A
OWNEDAUTO
SCHEDULED
AUTOHIREDS ONLY AUTOS
OVE-0001274-00
7/1/2024 7/1/2025
...
0DILYINJURY(Peraccident)
.Rr,Dg+ERT,Y,
..... .. . ..........,.,. ,
$
....__
If X
f X
Pr r.7APu4A6".,f.
"
is
...AUTOS ONLY AUTOS ONLY
$ Arvn3.Eti,
UMBRELLA LIAB UR
CLAIMS
RENCE
B
i X
. �
EXCESS LIAR -MADE
1 8EX4032
7/1 /2024
7/1 /2025
AGGREGATE
$ 5,000,000
....
I DED I I RETENTION $ O
'',
.......
$
WORKERS COMPENSATIONAND
PER
I
EMPLOYERS'LIABILITY Y/N
,.....,STATUTERH
E„L EACH ACCIDENT
......,. ......... .... .......
$
ANYPROPRI TOR/PARTNE EXECUTIVE
N A
..-
OFFICER/MEMBER EXCLUDED?
-
Mandato m NH
(Mandatory )
E.L DISEASE EA EMP OYEE�
L ...,.
$
......, ,..
If yes, describe under
j
DESCRIPTION OF OPERATIONS below 1
E.L, DISEASE- POLICY LIMIT
.
I
C
Accident Medical
TBD
7/1/2024
7/1/2025
PER INJURY LIMIT
$ 50,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Med Expense applies only to spectators at an AYSO Event. Certificate Holder is named as an additional insured when required by written contract or
agreement on a primary and non-contributory basis as respects AYSO sanctioned events only. General liability policy contains sexual abuse and molestation
limits of $1,000,000 per occurrence/$1,000,000 aggregate. This certificate is issued on behalf of: AYSO Region 92
r+ce ^rrernwac rani M=M f%AIkHB""r='t I A..T'Ink]
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,
ACCORDANCE WITH THE POLICY PROVISIONS.
officials employees, agents, and volunteers
AUTHORIZED REPRESENTATIVE
350 Main St
ElSegundo CA 90245
r
\./ i„c, Itliibbi-ZIU10 A+G,Yf ol+U A.°',tiJK.VUE7 IYd CV.An rlgnis reberve0.
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),
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 #
(X) 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 comply with those provisions or the agreement will automatically become void.
Signature of ApplicantDate 9.28.24
Print Name Brendan QgrLnley
Agreement for:
Dated:
Reviewed by: