PROOF OF INSURANCE (2025)DATE (MMIDDIYYYY)
"" C L � CERTIFICATE OF LIABILITY INSURANCE
o1/os/2ozs
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 CON Ac. Lauren Quinn
NAME:
ESP Insurance Brokerage, LLC PHONE (877) 670-2377 FAX
INC No„Frxt : AID_.
306 Main Street E-MACL lauren.kachadorian@espspecialty.com
ADDRFS,S:
INSURER(S) AFFORDING COVERAGE NAIC #
Worcester MA 01608 INSURERA: LIO Insurance Company 40550
INSURED INSURERB: Scottsdale Insurance Company 41297
International Pickleball Teaching Professional Association (IPTPA) INSURER c :
2 Lyngby Court INSURER D:
INSURER E
Riverwoods IL 60015 INSURER F :
COVERAGES CERTIFICATE NUMBER: CL2461935548 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.
INSR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE IINSO' WVD POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS
'" COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAN
CLAIMS -MADE � OCCUR PREMISES Ea oocurcenr.,e4$ 100.000
MED EXP (Any one Derson) $ 5,000
A ", Participant Legal Y L101100000283 07/01/2024 07/01/2025 PERSONAL &ADV INJURY $ 1,000,000
GENII- AGGR'EGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 4,000,000
POLICY EPRO LOC PRODUCTS - COMP/OPAGG $ 4,000,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMaINE:D INGLE LIMIT $ 1,000,000
Ea ,tt,t Idrrrar:
ANYAUTO BODILY INJURY (Per person) $
A OWNED SCHEDULED L101100000283 07/01/2024 07/01/2025 BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON -OWNED PROPERTYDAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLALIAB OCCUR EACH OCCURRENCE $ 2,000,000
B x' EXCESSuaB HCLAIMS-MADE CXS4027395 07/01/2024 07/01/2025 AGGREGATE $ 2,000,000
DED RETENTION $ $
WORKERS COMPENSATION PER ITH-
AND EMPLOYERS' LIABILITY �, I N LTATIITE� ER
ANY PROP RIETOWPART'NEMEXECUTIVE ❑ NIA E L, EACH ACCIDENT $
OF'RCERIMEMSER EXCLUDED?
(MandMory In N.H) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Coverage is Provided with respects to the pickleball certification process and the pickleball instruction provided and organized by certified member
teachers.
COACH: Nathan Staso
Additional Name Insured: EL Segundo Parks and Rec
Address: El Segundo Parks & Recreation, 401 Sheldon St, El Segundo, CA 90245
EL Segundo Parks and Rec
401 Sheldon St
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
ElSegundo CA 90245 I --- -- . -
@ 1988-2015 ACORD CORPORATION. All rights reserved.
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 ($1 t 00,),
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:
1 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 EI e
Policy No.
11 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 #
6 certify that, in the performance of the work set forth in the agreement
P g Bement 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 visions o the agreement will automatically become void.
Signature of Applicant Date
Print Name
Agreement for:
Dated:
Reviewed by: