PROOF OF INSURANCE (2026)CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 1 HIS
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„
IMPORTANP if the certificate holder Is an ADDITIONAL INSUR 0, the PDlicyliest ITll.lst have ADDITIONAL INSURED D glrovisltllls or Iae Morsed.
if SUBROGATION IS WAIVED, Subject to the terms and conditions Of the (IOIICy, Certain policies iflaI° require an endorsement. A Statement on
this certificate does not confer rights to the certificate holder in lieu Of such endorsenielit(S),
PRODUCER I NAME: Michele Reitz
Correll Insurance Group of Hilton Head . E�(8433) 785=-77 33
PO Box 6869 ADORESS: MAIL mreilz ,corcellhhi_com
COVERAGE
Hilton Head Island SC 29938 INSURERA: Philadelphia Indemnity
INSURED INSURE16,
Professional Pickleball Registry, Inc. INSURER C
PO Box 2516 INSURER 1)
COVERAGES CERTIFICATE NUMBER: 2025-2026 Master REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POLUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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_
T TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD II _WDDIYYyYI.,
X COMMERCIAL GENERAL (LIABILITY
CLAIMS -MADE � OCCUR
A PHPK2584296 09/01/2025 09/0112026
u"k LAGGRECATE L1Mrr APPLIES PER'
POLICY J� 0 LOC
OTHER
AUTOMOBILE LIABILrTY
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON-0WNED
AUTOS ONLY AUTOS ONLY
X UMBRELLA LIAB X OCCUR
A EXCESS LIAB CLAIMS -MADE PHUB875223 09/01/2025 09/01/2026
DED I X RI n NT ION S 10,0
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETORiPARTNERIEXECUTIVE �'
OF ERIMEMBER EXCLUDED? N 1 A
(Mandaitory in NH)
D R1 CN0.?FO EIS iIICASbeIow
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Eric Stenberg
Member # 136530
Effective Through: August 31, 2026
CHITIFICATECANCELLATION
Eric Stenberg
El Segundo, CA
NAIL M
18058
LIMITS
EACH OCCURRENCE S 1,000,000
PRBAuSES
'1U0,000
MED EXP { one person)
S Excluded
PERSZWL&ADVINJU
1,000,000
GENERAL AGGREGATE
S 0,000
fRQPUCTS - COMPrJP AGG
S 3,000,000
Eann
LILYNJ'URYdP Iverson;
s
SCOIL`(INJURY (Per aCN&nli
s
derh
S
S
EACH OCCURRENCE
S 5,000,000
AGGREGATE
s 5,000,000
S
STA LUTE I ER
E.L. HACCIDENT
S
E-L. DISEASE - EA EMPLOYEE
S
E.L. DISEASE - POLICY LIMIT
S
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE. EXPIRATION DATE'. THEREOF„ NOTICE WILL DE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS_
AUTHORIZED REPRESENTATIVE
c] 1988-2015 ACORD CORPORATION. All ngnts reservea.
A rnnn oc l'1A�crn�� -r�,.. A�^non ........... A �..,....a r.. �.....nt..�...i ...m.Le...f A! InMn
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN E IL.OYER 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 n4ritaln 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.
U 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:
Camer Policy Number Expiration Date
Name of Agent Phone #
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 becorno sub ect to t e workers" compensation provisions of Labor Code § 3700 I must
immediately comply with tho a rout ns or agreement will automatically become void.
Signature of Applicant - Date
Print Name
Agreement for.
Dated: