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PROOF OF INSURANCE (2025) CLOSED
„IC R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 10/16/2024 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 Kandace Kalln 02 Sports Insurance PH-0.NE ” tAIC, gtvk„fO 855 351 0202 tAA/xc, Ne) 1 855 984 2379 110 E Broward Blvd, Suite 1700 Fort Lauderdale, FL 33301 E-MAIL s Info o2sportsinsuranoWe Com _ INSURERS) AFFORDING COVERAGE, NAIC # INSURER A : Certain Underwriters at Lloyd's of London AA-1120157 .. NSURED INSURERB: e Corporation QBEInsurance 39217 EaglesEl 9 undo Youth Football and Cheer IMa of St.Se INSURER .......... - EI Segundo, CA 90245 INSURER D.: .. ....... .... ......... __...... .-. ........ .,,, ... ...................... ...... . . . ....... INSURER E : ......... ...- ............... ...................... ,... .. ............., __ ... ... A Member of 02 Program Management Inc., Athletic Association g g R F INSURER CnVFRArxF:R CERTIFICATE NUMBER: 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 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. _ _ .. -------- ... ..., ......AbtS'L'St 64S EFF LIMITS ILTR �.....,........... TYPE OF INSURANCE INS. WVD POLICY.NUMBER MM/OOY MM DDY..EXP X COMMERCIAL GENERAL LIABILITY 1 , EACH OCCURRENCE $1,000000 ,.. „...ry CLAIMS -MADE X OCCUR ' u'.F"r"m w. Ir-... P�PAA TO 42f N k. ........ �.,.... ...,,.. $300 000 ny one Person) 7/26/2025 0A 012 ��' A Y i 22BO6410-1407 00 AM 12:00 AM PERSONALBADV INJURY $1,000 000 ..... ... G,EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE . $3 OOO,OOO PRO- ❑ �........� POLICY I JEOTI. LOC PRODUCTS-COMP/OPAGG .....,,,.., ....- I $1000,000 .....,.. ...,..... ,. OTHEW PARTICIPANT LEGAL LIAR. $1,000,000 AUTOMOBILE LIABILITY T COMBINED SINGLE LWIT �p_Lover 4]... �s ...�.. -------------. } ANY AUTO BODILY INJ URY (Per per on) ..... .._.. - .......... .... ..,m.........- SCHEDULED �- AN ( ident) BODILY INJURY(Per acc AUTOS ONLY „AUTOS ROPIERT"Y OAdUAO3` ... AUTOS ONLY AUTOS ONLY EXCLUDING HAWAII UMBRELLA LIAB X, OCCUR '.. 10/Ol/2024 07/26/2025 -EACH. OCCURRENCE $1,........... 000000 A CLAIMS-MADEEXCESS LIARETENTION Y 22606410-1407 12:00 AM 12:00 AM ,AGGREGATE _ $1,000,000 j $ WORKERS COMPENSATION PER I TH STATUTE ER AND EMPLOYERS'LIABILITY YIN I „ ANYP OPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDEDo NIA ESL EACH ACCIDENT j . (Mandatoryin NH) -- DISEASE EA EMPLOYEEJ If yes, describe under DESCRIPTION OF OPERATIONS below i E.L. DISEASE- POLICY LIMIT Excess Accident Medical JAH000427 07/26/2024 12:00 AM 07/26/2025 12:00 AM Bene fit Maximum $100,000 g Y � Deductible Per Claim $250 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. Legal Liability to Participants (LLP) limit as a per occurrence limit. Claims by athletic participants are included. Sport(s): Cheerleading - Competitive (Association) Sexual Abuse or Sexual Molestation Liability - $1,000,000 each incident (included above) / $1,000,000 aggregate (included above). rr-0TIrlr AT unI DER CANCELLATION City of El Segundo, its officers, officials, agents, employees and volunteers 350 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 22BO6410-1407 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED i ED - MANAGERS S OIL LESSORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Entity (Additional Insured): City of El Segundo, its officers, officials, agents, employees and volunteers 350 Main Street El Segundo, CA 90245 Name of Insured: Eagles of El Segundo Youth Football and Cheer A. Section II — Who Is An Insured is amended to include as an additional insured the person or entity shown in the Schedule, but only with respect to liability arising in that part of the designated premises leased, licensed, or otherwise available to you and subject to the following additional exclusions: 1. This insurance does not apply to any loss, claim, "suit', cost, expense or liability for damages directly or indirectly based on, attributable to, arising out of, involving, resulting from, or in any way related to: a. Any 'occurrence" which takes place prior to your occupancy or after you cease to be a tenant in that premises or; b. Structural conditions, alterations, construction, demolition, maintenance or other operations performed by or on behalf of the person or entity shown in the Schedule. 2. Coverage (including defense) is provided only to the extent that liability is created for an additional insured by the negligent acts, errors, or omissions of the Named Insured. If liability for injury or damage is imposed or sought to be imposed on any additional Insured because of the acts, errors, or omissions of any additional insured or any person or entity under the direction or control of any additional insured, this insurance does not apply. Coverage for an additional insured under this endorsement shall be excess. Any other insurance the additional insured has shall be primary with respect to this insurance. Except as provided herein, all other terms, conditions, provisions, exclusions, and endorsements of this policy remain the same and applicable. Includes copyrighted material of Insurance Services Office, Inc., with its permission. HC-GL-40-020 01 17 Page 1 of 1 Eagles of El Segundo Youth Football and Cheer 10/10/2024 City of El Segundo Re: Business Automobile Insurance To whom it may concern, Eagles of El Segundo Youth Football and Cheer is an all -volunteer organization and does not own or lease any automobiles. Please let me know if you have any further questions. Thank You, Sylvia Bagues-Wagner President Eagles of El Segundo Youth Football and Cheer 531 Main St. #107 El Segundo, CA 90245 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: (_) 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. L_) 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 # LX_) 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 s `ect to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pf isio or agreement will automatically become void. Signature of Applicant Date 10/10/24 Print Name Ivia Ba _ a n Agreement for: Dated: Reviewed by: