Loading...
PROOF OF INSURANCE (2025 - 2025) CLOSED7 0 DATE (MMIDD/YYYY) AC40REX CERTIFICATE OF LIABILITY INSURANCE 64 ", 12/19/2024 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 2O.21;1" Racine rn1100Af±Cc WI 53405 t" COrtl::.'.IfIA.TF lidtiRAR00- 1009:inA171 RFVIAIn1N 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. ...... .... _ _... ..,,,...,__ ILTR TYPE OF INSURANCE LIMITS I INSD POLICY NUMBER V (MMIDD MMM301 X COMMERCIAL GENERAL LIABILITY u EACH OCCURRENCE $ 1,000,000 _.,..- ... i1FKAACI d i1r NfLd 1 000 000 CLAIMS -MADE X OCCUR ❑ �P,RFIMIISES.LEa,gccurrence,) $ MED EXP (Any one person) $ ..,EXCIUded A Y SBCGL0279607 08/01/2024 08/01/2025 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 PRO- POLICY ❑ ❑ LOC ,pE�CT i PRODUCTS- AGG ..... $ 5,000,000 _ v /\ OTHER: OFFICIAL AUTOMOBILE LIABILITY CrO,�yMBINLIi�'ySIN�GLE LIMIT 009gat .... $ _� ....... ... C(.T on) BODILY INJURY $ � OWNED SCHEDULED RY (Per acc U 'denl) $ AUTOS ONLY .,. AUTOS ........... HIRED NON -OWNED PROPERTYURY(Perpe DAMAGE Dy� .... .... AUTOS ONLY AUTOS ONLY (.+.Q_ ----------- UMBRELLA LLA LIAB X OCCUR .,EACH OCCURRENCE $ �,000,OOO A EXCESSR LIAR CLAIMS -MADE SBFXS0044407 08/01/2024 08/01/2025 AGGREGATE $ ,000,000 ........, .�...., ... . ....... RETENTION $ $ WORKERS COMPENSATION PER OT'H- AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E,L EACH ACCIDENT '"" $ OFFICER/MEMBEREXCLUDED? (Mandatory in NH) NIA - OYEE E.LDISEASEEEMPLOY .�..A EA EMPLO $ ..-_-- If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage applies to JOHN ZIELLO, 704 CAMINO REAL, REDONDO BEACH, CA 90277. - The Certificate Holder shall be an Additional Insured, but only with respect to the operations of the Named Insured, and subject to the provisions and limitations of Form CG 2026 - Additional Insured - Designated Person or Organization, effective December 19, 2024. CITY OF EL SEGUNDO, ITS OFFICLRS, ELECTED AND APPOINTED OFFICIALS, EMPLOYEES AND MEMBERS OF BOARDS, COMMISSIONS and volunteers 350 Main Street ElSegundo 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 ©1988-2015 ACORD CORPORATION. AN rlgnts reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: Aii AnnITMNAI RFMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED American Specialty Insurance & Risk Services, Inc. National Association of Sports Officials (NASD) POLICY NUMBER 2017 Lathrop Avenue SBCGL0279607 CARRIER NAIC CODE Racine, WI 53405 Arch Insurance Company 11150 EFFECTIVE DATE: 08/01/2024 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE -Certificate #1002309171 - Unintentional Errors & Omissions, $100,000 each occurrence/$100,000 Annual Aggregate per official/assignor (included in, and not in addition to, the limits shown in the Declarations of this policy) - Other Named Insured: National Association of Sports Officials (NASD) & NASO-member officials, including officials enrolled by associations, contracted with NASD, judges, referees, evaluators or other administrative staff of the officiating crew acting in an officiating capacity. - Other Named Insured (cont'd): NASO-member officials are only Named Insureds while acting in their capacity as officials during sports events organized by a recognized sanctioning body or organized by another entity, where the rules of a recognized sanctioning body are followed, such as a local Park Department or any formal organized association and/or while attending seminars, conferences, and similar meetings designed - Other Named Insured (cont'd):to improve their officiating knowledge and skills and/or mentoring or providing instruction to or evaluation of another official. - Other Named Insured (cont'd): LLC's that are created by an NASO member officials for the sole purpose of handling payments from officiating and assigning activities. It is further understood and agreed that NASO member officials and his/her respective LLC is considered to be one entity for the purposes of coverage throughout the policy and all amendatory endorsements. - The excess Aggregate Limit applies separately to each ""official" insured under this policy. However, in the event of a suit by one or more plaintiffs against more than eight "officials", the Aggregate Limit will not apply separately to each "official", and a single aggregate limit of $20,000,000 will apply collectively to all individual "officials" covered under this policy. - The General Liability policy is primary and non-contributory as per Form CG 2001 Primary and Noncontributory - Other Insurance Condition. ACORD 101 (2008/01) U ZUU5 AGUKU UUKI'UKA I IUN. Au ngnis reserves. 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 A to Z Officiating. Date:I- V-Z,� � aA=4S.-L By: Darrell George, City Manager "I DRNIA )jte CA-Lof—F INSURANCE (..,.,A,RD I Stzite Farm Mutual Automobile Insurance Company PO Box 2358 Bloomington IL 61702-23518 INSURED ZIELLO, MARY'& JOHN E MUTL VOL POUCY N(MBER 721 3,031-FOI-75 EFFECTIVE SEFE R E VE R S E S I D E F01 RI AN, EX 1"LANATI 0 N 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 ($900,000), 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. (_) 1 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 Name of Agent Policy Number Expiration Date 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 agreet to �- compensation provisions of Labor Code § 3700 1 must immediately'compfY wittc see rs a workers' Iutomdtically become void.. Signature of Applicant Print Name Agreement for: Dated: Reviewed by: LCE, V-) Date