PROOF OF INSURANCE (2025)" [ DATE (MM/DD/YYYY)
A CERTIFICATE OF LIABILITY INSURANCE
8/1I2024
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
RPS Bollinger PHONE FAat
200 Jefferson Park �Oaa ss xts Oro 446-5 �. t �Ne) 74
800-446 5311 97 . 921 84
Whippany NJ 07981 EMAII p , (aslV1S Corr"
INSURERA,,.,, Markel... I_11111nsurance Company.. -..--- ............. �.. .38970
US Plaza Del ball League
#808 INSURED INSURER a Markel Insurance Company 38970
US Youth Volleyball Lea ue
INSURER, C __ -_ �,... .-.. -- ...... , . .....�
Torrance CA 90503 NSUReRpmm
INSURER E
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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,
--------
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TYPE OF IN••...
I_TR..... SURANCE POLICY NUMBER
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�COMMERCIAL GENERAL Y i 3602AH028574
A CO�
8/1/2024 8l1/2025 EACH OCCURRENCE p$1000,000
�ISAMAi�RENi�"i.�
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X
CLAIMS -MADE I OCCUR
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MED EIXP (,(.7
n one $,5 000
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PERSONAL & ADV INJUR Y $ 1 000 000
EG..
I
3 000 000
EML AGGREGATE LIMIT APPLIES PER:
ENERALAGGREGATE
.....L _ $
X POLICY LOC 1
§H.CT......
RODUCTS COMP/OP AGG $ 1.000 000
„�
OTHER.,
$ 1 mil/$2mil
Sexual Abuse/Mol mil
A
I AUTOMOBILE LIABILITY
f
3602AH028574
8/1/2024
8/1/2025
COMBINEE
000
$1000
i-
ANY AUTO
1
VV L.BDODILY INJURY(Pe person)
$
OWNED SCHEDULED
I
BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
X HIRED l f NON -OWNED
V--�
I5ROPERY`f DAMAGE
$
AUTOS ONLY X AUTOS ONLY
.............
... ...... —
$
A
UMBRELLA LIAR X
�,-_-, OCCUR
4602AH010560
8/1/2024
8l1/2025
OCCURRENCE
EACH OCC
. $1,000,000
X
EXCESS LIAR CLAIMS-MADEi
AGGREGATE
1 $1.000 000 ...,.
tm
DED C'X I RETENTION $
I
f
$
WORKERS COMPENSATION
I
I STATUTE �RH
.. ....
AND EMPLOYERS LIABILITY Y / N
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,.. ,.
$
'ANYPROPIRIEfOPWARTNER/tXECUT'k'oPE�„.
E�L EACH ACCIDENT
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f (Mandatory in Ni
N/A
s
P
E.L DISEASE EA EMPLOYEE
.
$
4OFFiC.EReMIndkBEREXCIWN,RDRLik'N
Itly�ew ,u d""be under--
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� E_L, DISEASE POLICY LIMIT
� $
DESCRIPTION OF OPERATIONS below
B Accident Insurance
4102AH028573
8/1/2024
8/1/2025
Med Max:
Dad:
$25.000
$100
Full Excess
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may i attached if more space is required)
The certificate holder is named as an additional insured under the liability policy.
Coverage is provided for sponsored/supervised activities of the named
insured.
The City of El Segundo, its officers, officials, employees, agents, and volunteers
are included as additional insured
30 Day Notice of Cancellation Applies
Group Code: 0
ULK 111-Il;A l t MULLFI-K 1 —1.
The City of El Segundo, its officers, officials, employees,
agents and volunteers
401 Sheldon Street
El Segundo CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTTHHOORIZ--EeeD RREEP��R,,E``SENTATIVE
lcJ T`J60-LU"10 AI.VRU LVRI'Vrc/±1 rvr�. nu rryrraa rcacrca..
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:
(U 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 Policy Number Expiration Date
Name of Agent Phone #
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 ubject to the workers' compensation laws of California, and
agree that, if I should bec m subject to the wor rs' c pens provisions of Labor Code § 3700 1 must
immediately comply with t sZprovisions or the eerie ill eu tically become void.
Signature of Ap idant ✓ Date
V
Print Name . ` " ,. L
Agreement for: 74V
Dated:
Reviewed by: