Loading...
PROOF OF INSURANCE (2025)A ��w. DATE (MMIbDIYVYY) ._ r'CERTIFICATE OF LIABILITY INSURANCE L1ra4/202a CAFFIRMATIVELYISSUEDAS A CERTIFICATE DOES NOT OR NEGATIVELY ION ONLY A OR ALTER THE COVERAGE THIS F CERTIFICATE MATTER OF INFORMATION AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS AMEND„ EXTENDVERAGE 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 SdIF' Frazier Insurance Agency. Inc P 0 Box. 1250 Midlotian VA 23113-1250 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION PHONE IA,C, No E M[ (804) .754-7610 E.MW L AICPDRIF.::SS. INSURER(S) AFFORDING COVERAGE INSURERA (ina tAn-if,, r&RI"I I'1 4d1 �'I 1f f,'rD( Cel Uj�;'d I`1'7 INSURERS: INSURER C : FAX (AIC, N.g: i80 4) 754--7613 NAIC N 16691 El Segundo Inline Hockey Association INS„RERD: PO Box 3061 INSURER E: 90245 INSURER F - Sei,undo, CA _. w I COVERAGES CERTIFICATE NUMBER: �.�.�..__.. _. REVISION NUMBER, --- -THIS IS DCCERTIFY THA1 I -HE POLICIES O INSURANCE LISTED SYiCW HAVE FFEV ISSUED1CIIIBNBEFFCNAMED ABOVE ..._ FGDVt 6V§°ri POLICY I�'FF89or1CD INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OrHER: DOCUMENT WITH I RIF SPC C T I0 UVIIfICH THIS S C.ERTI ICATll:.! MAY RE ISSUED OR MAY PERAIN THE INSURANCE AFFORDED BY THE F>611LIC.IH S DESCRIBED HEREIN IS SUBJECT 40 AI lI. THE TERMS EXCLUSIONS AND CONDITIONS OF SUCFi POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR AD'OL: SUER i*OLIGY' Erh r�dS C.IG:Y EXP rS TYPE Ot INSURANCE ON*A`D' WVD POLICY NUMBER DE6tl�"DWYYYVI IMAtlrowy YYYp LIMI - X COMIME RL uAL Gr.IIQERAI.. LOABok..u'EY �ru,I 1,000,000 00 cED�I au ewkC¢ cc;uR I a I il ��� :300.00&00 A ;K n,l !:,, r)o;; 1 + Ir I KAPIrwl T � PAC 4725034 '.:; 1' 1 r „i I IV] iAPO. k S A'N `q Y, BayD. AUD OMOffD0L11: LIIA.BWT'Y ANY (AUTO OWNS: Ct ,r 171J I::U Ai TOS ONLY }I I I "S HbRT :D NON 00'r'a1.I:1 AU 7OS T NL.Y 111 ",9 QNL..'r' UMBRELLA L.IAS I ,C U H EXCESS LdAB i l ,r dM , d'b'ID',C11 ,Dl_I� .d III,uY11�1',d mss 'UvgPORIKI RS 46SghARlf E NSAUOOADV11011,�....-�......_ ..� 4 AND II::.MIF"II..OYERS'L)AIF%VE..I Y YIN',,. >,NY PROi 'RIETC)l:iiPART1` I:.: R/E:XEI,,' JT(VE QFP N I A IMandakoiry M NU09 Of �1� rf aw r GE G9t F' I ,+a 1 , F'E FEAIIC N5 CaeVowr 01/04/2024 01/04/2025 12:01 AM DESCRIPTION OF OPERATIONS I LOCAT IONS /VEHICLES IACORD 101, Additional Remarks Schedule, maybe attached IF more space is require CERTIFICATE HOLDER El Segundo lnline Hockey Association PO Box 3061 El Segundo, CA 90245 CANCELLA Af I 1 ii (A'ia �u d, Ix, a:,ru a LIIC C.1i 19„I I, A I lrI,I �r 4a dYi;Y171-C,',�'Y0+ r;E 1 LIW n,,01AI i_„E11'_.. _ nU.l1VVlV 41N.:>kT I.4l;Ii a I'4v,17^l',I "; ..I 19 vile Al v, ra 2 c i10 000 00 a PI'Uf 1111 I IlN'AJl''U w IV ^o a u:ata nVl i� Iti:�M,r1 w�a.I Nr,l___ t l Dl„I A'[ i AI ,AP1..0fl I.: E k M EASIE N'"'+9.AGY 4. VWiT la SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 16fin `W. Frazier ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 2016103) The ACORD name and logo are registered marks of ACORD " '»red AC DATE (MWDDYY" CER�'TE „OCCINIDYINSURANCE 1/04/2024THISCEIFiCATE IS ISSUED ASEROFNFORMATIONONLY AND RIGHTS UPON THE mmmmIT 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. IMPORTANTr 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 Frazier Insurance Agency, Inc 7E_MAIL FAXP O Box 1250 (804) 754-7610 I,c (804) 754-7613 Midlothian, VA 23113-1250 N 71111 11 Pqury0 roV WrpV'I' IV^Mq 1`tl rAv ll'II'Parhu ll,;; NAICa INSURED SPORTS �... INSURERA f,41^r!rPArri ncs.,v'rlCl a sr]C°e �ofnpaw)yr 16691 RTS AND RECREATION PROVIDERS ASSOCIATION INSURER B INSURER C El Segundolnline Hockey Association INSURER D: PO Box 3061 INSURER El Se undo, CA 90245 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: Y TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD� THIS i�i TO CERTIFY THAT THE POLICIES 01 INSURANCE LISTED BELOW HAVE BEEN I;iv':�LUEI CY INDICATED D NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITION'S OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR 'ADOI,'SIIARRT-- POLICY15FT ' POII. CYT-SdP'v RAN INSO 'yNV1GVPOLICY NUMBER ....... MMJD "Y' Y d, ,..�.,� OOPNYYYY L.'ITE i ) LIMITS �...�, ..,�........ ��, MMERCIPALOCaENEINSURANCE ��,,....._.�._.ILITtl �r,.....,._....�,. AL A� a°� i, r rt,. L) 1d47Lp G.,kt 0G0,o00_ 300MC V c) aaPk� yr r ,u CLAIMS -MADE X OCCUR ., .C'tib a� rr°rvxx ,� A e 01 /04(2024 I tl e`01 I ru ��� �� 10,000 00 HL Ilvr u.I,aI::P. � ATHu.r::roc rsn ztilr:uPFtlwUr:, PAC 4725034 AIM Pq I RnRY 'II 000,000 00 i. I rl A ,4'E I_ rA '.. C..II H z PL1 f:i 1:1 P',,' GENERAL AC C RI radian a 2 00 ,000-00 L t a, 2 000,0 0 00, mT .iY,�li bUU'ttr�IrvArsr�!PIT� F', I.. IAP:9PII..irr1P` iA~a A.. C.r rvlj ANY'AU 0 I,''f 011 .''Y INJU Ile, rx,U, OWNED I... '(::1"1k:.L.7C71LA_D I':!61 iUL "'I'' IN piW-111N, ,%x;: f rill W ALITOS ONLY Are rOS sowA 9E HflRED NCuw-tND E, K, tioN,Yr AUPVti>CrllPP AlY',;CAEY " .Y.. ,>. _ UMBRELLA L AS C)q„y;iJR... a'.. V v 4 1 LIII I I hdr IIE 5 EXCESS 1t..IlA&:q f"L.F#fIM S-IVGAhC:kE:' 1v Ixl ) A'V"I ry WORRGIE RS COMPENSATION , StlArI.I'Tr ralr A II4O r.MlPILOYIER:'L.tAIK.UUATY YIPSANY ..- �BERE�.XG;I..t D..'.0XP:.C'i,..76116r:: OFF NIA IC L I>I.. FASE I "G d-d,AirnI_o vr1 ro lU avdwRMYEETORJPAR orcu 1141R Uc0Y fkLW, vroc�9a r' ¢ ,rC,r�°IP'fil1"„vX�k (dl 4)I ti:PAtiUIC)IV;u Ys¢+d+�+ev E V. DISEASE /W4:Mr Il(A PC,' I IIIV.YI11 ........,�...._ .._._.-,......w._,.�.,........ m ....�....�..�... .......... ................ ............... ...._....�..........�,.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addifi—I Remarks Schedule, may he attached If more space is required) ......A..A, .... ._..�,,, .......�..,.,�-�.m.... Certificate Holder is An Additional Insured, But Only As Respects The Operations Of The Named Insured CERTIFICATE HOLDER. -. � ..��-�..._ .�_ ..�.._.... CANCELLATION __ , ._.��..".. ...... ... , ,,._ he City Tof El Segundo, its officers, officials, employees 350 Main 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. AUTHORIZED REPRESENTATIVE John W. Frazier ACO __.._ RD 25 �20i61..03) ....m, .. _. ....... , ,_,_ ., _ ........ ... .. _ ©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: 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. C_) 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 mploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subj o the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pr sions or th agreement will automatically become void. I Signature of Applicant Date A C' ` `i 2 `� Print Name' 3 Agreement for: . � ,f,\^ N" \3,( k " ( �sC OC, o-VI doh Dated: Reviewed by: