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PROOF OF INSURANCE (2025 - 2025) CLOSEDA.rr"" "R" DATE (MMIDDIYWY) CERTIFICATE OF LIABILITY INSURANCE 10/16/2024 _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH IS 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 PRODUCER ooNTc' Kanda_ .. ce Kalin 02 Sports Insurance PHONNE" FA. nlr • 110 E Broward Blvd, Suite 1700 009P.BR.,E ) _=855 351 0202 --- t AfX 1 855-984 2379_ t MAts. Fort Lauderdale, FL 33301 ADe1fxEs ,., o,2s ,o�rlsinsurance .., ... ....__ _ com _ � .. ... .. �.. INSURER(S) AFFORDING COVERAGE NAIC q INSURER A: Certain Underwriters at Ll .. ......... __.. Lloyd s of London AA-1120157 INSURED .. ... �.. .......... ......... ..... ..mm, _ ........�..,-...,,.. ,_� COrpOfB.... .�,,.,.,.,.,... ,..........� INSURER B QBE Insurance Eagles of El Segundo Youth Football and Cheer ......... .. lion .I 39217 531 Main St. INSURER C El Segundo, CA 90245 INSURE.R..�.... _ INSURER E A Member of 02 Program Management Inc., Athletic Association INSURER F COVERAGES 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. ILTR -— .... TYPE OF INSURANCE... .....,.........., A6,19:VG�. SUEF2:. ..............POLICY NUMBER .. MG PO�LFICY EFF P0ICGCY UXP LIMITS ..,�,_,,..,. .., .....,.., .. M$d�YD D/'YYYW ... COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE - $1.000.000 CLAIMS -MADE /\OCCUR DAMAGE TORENTED P..IISESIE $300,000 ny one Person) 7/26/2024 A y 22806410-1407 012:00 AM 012:00 AM5 PERSONAL A&ADV INJURY $1,000,000 GLN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3 00Q 000 8C} PRO- LOC PRODUCTS COMP/OP AGG $1,000,000 PARTICIPANT LEGAL LIAB� 6 JECT � BODILY�NJURYOPer person) -•...DDD AUTOMOBILE LIABILITY _ PA 1 000, ANY AUTO I,--- I— "i OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED � I r la.�n'+aAK,i;. r AUTOS ONLY AUTOS ONLY EXCLUDING HAWAII 10/01/2024 07/26/2025 EACH OCCURRENCE $1 ODO,ODD EXCESS LIAR _ .�_ Y 22806410-1407 12:00 AM 12:00 AM AGGREGATE $1 OOO,OOO A �� UMBRELLA LIAB OLAIMS MADE .,,_. ..... ... ........ _„ ___ .e..... .. DED RETENTIONS W .M. rvrv... ............ WORKERS COMPENSATION _ STATUTE FORH OFFICER/MEMBER EXCLUDED E L. DISEASE - a DENT ANYPROPRIETOR/PARTNER/EXECUTIVE AND EMPLOYERS'LIABILITY Y / N N / A E L.. EACH ACC . (Mandatory In NH) .... ...............�......................EP.-EMPLOYEE..............................,.....,.,.,._...........,........... If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 6/2024 Benefit Maximum 0,000 B Excess Accident Medical Y JAH000427 01/2�00 AM 012 00 AM Deductible Per Claim $10 $250 DESCRIPTION OF OPERATIONS I LOCATIONS I 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). CERTIFICATE HOLDER 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 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, et ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 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 - MANAGERS OR 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. 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 CALIFORNIA INSURANCE CARD Stale Farm Mutual AulomobilmIFe It1tiLEialti �w company I SOi II) 30�.J iIA ING"Y+IIL,LIIAM & FTO ILIA MUTL VOL POLICY Nl1MOER32314IJ AOI•75O IR 2Q15 MAKE NISSAN I FFE iU E MOOR PATHF14DER Yl�tl JAN 01 2025 Lf JUL OV 2iL2S �ll,l N' FO BARNHART i'H"r` S310 22 0 (I' NAIi w 5+1-A 5 PREiFiF4LwL P VIDFO DY 7IIE POLWV MEFT35THE M1 NIMUP,11,BAOIl.iry L1?4li"ts PRE Cg11L1CGk flY LAW cov Nat ES A L.V LBO SEE REVERSE SIDE FOR AN EXPLANATION, 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. (_) 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 # Zil 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 subj9 to - . wor „m rs' compensation provisions of Labor Code § 3700 1 must Signature ly A ian P � i ns o � a ,m nt"Wil ,automatically become void. immediate) complywith those, rdrvis�o Date 9 pp �.-. Print Name Agreement for: Dated: Reviewed by: _