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PROOF OF INSURANCE (2025 - 2025)ACVRO CERTIFICATE OF LIABILITY INSURANCE DATE(MWODIYYM 08/15/2024 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(io ) 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 A' NAMichele Reitz ME: Correll Insurance Group of Hilton Head PHONE (843) 785-7733 FAX PO Box 6869 E-MAIL _prr): A00 tESS: mreitz@correllhhi.00m INSURERISI AFFORDING COVERAGE NAIL 0 Hilton Head Island SC 29938 INSURERAz Philadelphia Indemnity 18058 INSURED INSURER B Professional Tennis Registry, Inc. INSURERC: Professional Pickleball Registry, Inc. INSURER D : Professional Platform Tennis Registry, Inc. PO Box2516 ........... . INSURERE: Zephyr Hills FL 33539 INSURERF: COVERAGES CERTIFICATE NUMBER: 2024-2025 Master 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 MAYBE 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. LTR '... TYPE OF INSURANCE INSD POLICY NUMBER MI EF MIMI LIMITS......... >< COMMERCIAL GENERAL LIABILITY EACH 1,000,000 CLAIMS -MADE © OCCUR OCCURRENCE T+REImtNS'ES (Ea oaxuarance,�� $ •....... $ 100,000 MED EXP An ana n) $ Excluded A PHPK2584296 09/01/2024 09/01/2025 PERSONAL &ADV INJURY $ 1,000,000 I".,F,.ri3OLA,f~aGRE� LIMITAPPLIES PER: GENERALAGGREGATE $ 3,000,000 raw PRO- ❑ LOC POLICY .PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY CU-0NED IN LE LIMIT $ IWa a;ccidtxnl� ANYAUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY UTOS BODILY INJURY (Per acaderd) $ '.. HIRED ON -OWNED PROPERTY DAMAGE. Prnr acxVdpl„„ $ JAUTOS AUTOS ONLY ONLY $ X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE PHUB875223 09/01/2024 09/01/2025 i DEDJX RETENTION 5 10,00.0 $ WORKERS COMPENSATION I PER AND EMPLOYERS' LIABILITY Y f N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE E.L.EACHACCIDENT $ OFFICER/MEMBER EXCLUDED? N f A (Mandatory In NH) E: L DISEASE - EA EMPLOYEE $ If Yes, describe under DESCRIPTION OF OPERATIONS belay E.L. DISEASE - POLICY UMrr $ ........ _.......... DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) [Job#: 75 Job Type: ] 132885 - Certificate Holder is listed as Additional Insured # 75 with respect to Member # 132885 - Penelope Finders . 401 Center Street , El Segundo CA 90245 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, a ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD INSURANCE WAIVER Pursuant to Section 4 of El Segundo City Council Resolution No. 4813, the undersigned authorized the waiver of commercial auto insurance for the City of El Segundo instructor contract with Penelope Finders Date: Z By: Darrell George, City Manager GAA 0, 1 73622144 Effective Date: ,08-2 -24, txpirabion Date. UIO-z I -/-,j This policy provides at least the miinimum of 11abillity insurance required by the CA VEH CODE SECTION '16056 f"mr-the Sp, /,if ed 6 vehicles and named insureds. Coverage adb and l,imits, 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: have a� iu 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. (_) 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 # 01 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 p " " � nt will automatically become void. Signature f Applicant with those rov n^s or the reerne �u ,� Date Print Name Agreement for: Dated: Reviewed by: