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PROOF OF INSURANCE (2026)DATE (MM/DDIYYYY) A" I?L> CERTIFICATE OF LIABILITY INSURANCEF101 812025 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 ... - _ --- ... PHONE' HOu Nq. American Specialty Insurance &Risk Services, Inc. PHONE *t) R✓ Np1, dba A.S.I.R.S.I. Insurance Agency CA License #OE72661 E-MAIL F — 7609 W. Jefferson Blvd., Suite 100( ) AOORFSS. INSURER(S)AFFORDING COVERAGE -- N ee AIC # Fort Wayne IN 46804 INSURERA: Arch Insurance Company 11150 11111- __ -1- -.-.- -- __ INSURED INSURER B : National Association of Sports Officials (NASO) INSURER C : -. 2017 Lathrop Avenue INsuREaD ...... ..... ... _...... - -------- _---- --- INSUREREt ... ...--- I Racine WI 53405 1 INSURER F i r r�%JOMAO•ce P`00T1U1d ATC MIIIIAI2P0• 9nn9anRRnR RFVISInN NIIMRFR- 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. ...... ....... .......TYPE OF INSURANCE......... ..... � , POLICY NUMBER ,�-�.....(MMIDDMIYY MMID .... LIMITS INSR ,. �A136L.'StBR POLICY EFF POLICY EXP t I COMMERCIAL GENERAL L 1 � EACH OCCURRENCE $ 000� � ,... .. ---- CLAIMS -MADE XLIABILITY 1 �/ 1 I OCCUR -E,Af,PALwCn t t- PREMISES Rrop n [may 0 $ 1 000, 000 E tl -,I i An one erson) $ A Y SBCGL0279608 08/01/2025 08/01/2026 PEDEXP $ 1 OOO,OOO �5 . .... ................ GENLAGG REGATE LIMIT APPLIES PER. 'Ro s GENERALAGGREGIA ERY 000 000 1 5 OOO OOO POLICY 9ECT LOC PRODUCTS - COMPIOP AGG - _ $ ........ ..... 1 X ! 01HEiR. OFFICIAL I $ AUTIOMOBILE LIABILITY ' COMBINED VN GLr LIMIT a Pdem.1 $A ANY AUTO BODILY INJURY (Perperson) $ OWNED SCHEDULED �,,,,, AUTOS ONLY AUTOS —- BODILY INJURY (Per accident) - $ -----------..._. P 47p1=R1 Y I%AMA'OE $ AUT05 ONLY AUTOS ONLDV ( t� r�smar.��d.L.ntl ........ .. ..� Is JX� UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A _ EXCESS LIAB CLAIMS -MADE SBFXS0044408 08/01/2025 08/01/2026 ...... ...... ... AGGREGATE $ 0 9 000,00,,. ------------------ - --- j DED RETENTION $ WORKERS ORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE STASUT PER E I ER,YIN E.L.EACH ACCIDENT ,,,,,,,. _...... $ r"""� OFFICER/MEMBER EXCLUDED? NIA "' ""'' - .-._ Mandato in (Mandatory ) E,L_-DISEA5E EA EMPLOYEE $ If yes, describe under __.. ....__....... .... ... ., $ DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT 7 . .......... . . , If I DESCRIPTION OF OPERATIONS / LOCATIONS / 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 October 28, 2025. r PRTICIreTP I4n1 nFR CANCELLATION CITY OF EL SEGUNDO, ITS OFFICERS, 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 U 1988-2U15 AGUKU UUKYUKA I IUIV. AU rignis reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: Ate, ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED American Specialty Insurance & Risk Services, Inc. National Association of Sports Officials (NASD) POLICY NUMBER SBCGL0279608 CARRIER Arch Insurance 2017 Lathrop Avenue NAIC CODE I Racine, WI 53405 11150 EFFECTIVEDATE: 08/01/2025 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER ACORD25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE - Certificate #1002408608 Page 1 of 1 - 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 (NASO) & 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): NASD -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 CIS 2001 Primary and Noncontributory - Other Insurance Condition. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reservea. 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 ($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 # G1 certify that, in the performance of the work set firth 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 agree that, if I should beco e e subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with rNsiq 'jL ptomatically become void. Signature of Applicant Print Name Agreement for - Dated: Reviewed by: U�+ LteL—�� Date