PROOF OF INSURANCE (2009) CLOSEDDATE (MM/DDNY)
t � 4/09109
CORD'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
FOR SERVICE CALL: THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
FRANCIS L. DEAN & ASSOCIATES OF FLORIDA, LLC COVERAGE AFFORDED BY THE POLICIES BELOW.
OCALA, FLORIDA COMPANIES AFFORDING COVERAGE
877/671 -3326
www.fdoanfl.com COMPANY RIVERPORT INSURANCE COMPANY
A
INSURED SPORTS AND REC. PROVIDERS ASSN. PURCHASING GROUP
TriFytt Sports
1500 S. Anaheim Boulevard, Suite 220
Anaheim, CA. 92805 Cart #AP107754 -00
COMPANY
C
COMPANY
D
em x . �. 4,..
RIP
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.
CO
LTR
TYPE OF INSURANCE
POLICY
POLICY NUMBER DATE
EFFECTIVE
MWDD/YY
POLICY EXPIRATION
DATE MM/DD
LIMITS
GENERAL
LIABILITY
GENERAL AGGREGATE
$ 2,000,000.00
A
X
COMMERCIAL GENERAL LIABILITY
PRODUCTS - COMP /OP AGG
$ 1,000,000.00
CLAIMS MADE FX7 OCCUR
WRD 180010
6/13/08
6/13/09
PERSONAL & ADV INJURY
$ 1,000,000.00
OWNER'S & CONTRACTOR'S PROT
EACH OCCURRENCE
$ 1,000,000.00
X
FIRE DAMAGE (Any one fire)
$ 300,000.00
INCLUDES ATHLETIC
PARTICPANTS
MED EXP (Any one person)
$ N/A
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
$
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
UMBRELLA FORM
$
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
we srU.,- oTH-
TORY LIMITS ER
EL EACH ACCIDENT
$
THE PROPRIETOR/ INCL
PARTNERSIEXECUTIVE
OFFICERS ARE: EXCL
EL DISEASE - POLICY LIMIT
$
EL DISEASE - EA EMPLOYEE
$
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONSIVEHICLES /SPECIAL ITEMS
THE CERTIFICATE HOLDER IS ADDED AS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF OPERATIONS OF
THE NAMED INSURED DURING THE POLICY PERIOD.
W.. „ Sx z4i �fin
City of El Segundo
City Hall
350 Main Street
El Segundo, CA. 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL
MAIL _30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER
NAMED TO THE LEFT.
Francis L. Dean
ADDITIONAL INSURED
Date(MM/DD/YY)
6/3/2008
AGENCY IacQrNio�h 800- 745 -2409
FAX
(A/C, No,(: 630- 665 -7294
FRANCIS L. DEAN & ASSOCIATES, INC.
1776 S. NAPERVILLE RD., BLDG. B
P.O. BOX 4200
WHEATON, IL 60187
APPLICANT (First Named Insured) c, N
ah
TriFytt Sports
1500 S. Anaheim Boulevard, Suite 220
Anaheim, CA 92805
EFFECTIVE DATE
6/13/2008
I EXPIRATION DATE
6/13/2009
CO /PLAN
CODE: suecoDE:
AGENCY CUSTOMER ID
POLICY NUMBER: WRD 180010
ACCOUNT NUMBER:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Sunrise Christian School
1220 Ruddock Street
Covina, CA 91724
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: -77CERTIFICATE REQUIRED
Clark Co. Park & Community Services
2601 East Sunset Road
Las Vegas, NV 89120
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: I BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE* CERTIFICATE REQUIRED
City of Walnut, its officers, agents and employees and the
Walnut Valley Unified
School District,
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
The City of Yucaipa
34272 Yucaipa Blvd.
Yucaipa, CA 92399
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Santa ana,
20 Civic Center Plaza
Santa Ana, CA 92702
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE M CERTIFICATE REQUIRED
Christ The King Catholic Church
4925 South Torrey Pines Drive
Las Vegas, NV 89118
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE M CERTIFICATE REQUIRED
UCCSN /UNLV
5550 West Flamingo Road, Suite C -1
Las Vegas, NV 89103
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
ADDITIONAL INSURED
Date6/32 D0$/YY)
AGENCY PHONE g00- 745 -2409
INC, No, Eat):
FAX
(AIC. No,): 630- 665 -7294
FRANCIS L. DEAN & ASSOCIATES, INC.
1776 S. NAPERVILLE RD., BLDG. B
P.O. BOX 4200
WHEATON, IL 60187
APPLICANT (First Named Insured) Phone
(NC, No, Eap:
TriFytt Sports
1500 S. Anaheim Boulevard, Suite 220
Anaheim, CA 92805
EFFECTIVE DATE
6/13/2008
EXPIRATION DATE
6/13/2009
CO /PLAN
CODE: SUBCODE:
AGENCY CUSTOMER ID
POLICY NUMBER: WRD 180010
ACCOUNT NUMBER:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Brea
695 East Madison Way
Brea, CA 92821
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Allyn B. Scheu
P.O. Box 250
Upland, CA 91785
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Charter Oak School District
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Laguna Niguel
27801 La Paz Road
Laguna Niguel, CA 92677
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: I BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Anaheim
200 South anahelm Blvd.
Anaheim, CA 92805
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Dana Point,
33282 Golden Lantern
Dan Point, CA 92629
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: I BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE* CERTIFICATE REQUIRED
City of Orange,
300 E. Chapman Avenue
Orange, CA 92866
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
ADDITIONAL INSURED
Date(M Y)
6/3/22008 008
AGENCY PHONE Exll 800- 745 -2409
(A/C, No,
630- 665 -7294
FRANCIS L. DEAN & ASSOCIATES, INC.
1776 S. NAPERVILLE RD., BLDG. B
P.O. BOX 4200
WHEATON, IL 60187
APPLICANT (First Named Insured) Phone N: o, E
(A1C, FI)
TriFytt Sports
1500 S. Anaheim Boulevard, Suite 220
Anaheim, CA 92805
EFFECTIVE DATE
6/13/2008
I EXPIRATION DATE
6/13/2009
CO /PLAN
CODE: SUBCODE:
AGENCY CUSTOMER ID
POLICY NUMBER: WRD 180010
ACCOUNT NUMBER.
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE M CERTIFICATE REQUIRED
City of Tustin,
300 Centennial Way
Tustin, CA 92780
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of West Covina,
1444 West Garvey Avenue
West Covina, CA 91790
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Lake Forest,
25550 Commercentre Drive, suite 100
Lake Forest, CA 92630
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Fullerton
303 W. Commonwealth
Fullerton, CA 92832
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE M CERTIFICATE REQUIRED
City of Irvine
1 Civic Center Plaza
Irvine, CA 92623
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
The Upland Indoor Sports Arena
1721 W. 11th Street
Upland, CA 91786
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE* CERTIFICATE REQUIRED
City of Costa Mesa
77 Fair Drive
Costa Mesa, CA 92626
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
ADDITIONAL INSURED
Date(M Y)
6/3/22008 008
AGENCY
PHONE 800 - 745 -2409
(A/C, No, E t):
APPLICANT First Named Insured Phone
( ) (NC, No, E.):
TriFvtt Sports
FAX
630- 665 -7294 1
FRANCIS L. DEAN & ASSOCIATES, INC.
1776 S. NAPERVILLE RD., BLDG. B
P.O. BOX 4200
WHEATON, IL 60187
EFFECTIVE DATE
6/13/2008
EXPIRATION DATE
6/13/2009
CO /PLAN
CODE: I SUBCODE:
AGENCY CUSTOMER ID
POLICY NUMBER: WRD 180010
ACCOUNT NUMBER:
INTEREST
RANK:
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
City of Newport Beach, its Directors, officers, agents and employees
3300 Newport Road
Newport Beach, CA. 92663
INTEREST IN ITEM NUMBER
X
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Wawasee High School
#1 Warrior Path, Building #1
Syracuse, IN. 46567
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
F
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
I RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Hoover High School Freshman Campus
6055 Flemings Parkway
Hoover, AL. 35244
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Hoover High School
1000 Buccaneer Drive
Hoover, AL. 35244
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Hoover Board of Education
2810 Metropolitan Way
Hoover, AL. 35243
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Santa Margarita Landscape and Recreation Corporation (SAMLARC)
Merit Property Management, Inc.
1 Polaris Way, #100
Aliso Viejo, CA. 92656
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
Antioch Sports Complex
314 Eross Street
San Antonio, TX. 78202
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
ADDITIONAL INSURED I Date (M2008 Y)
6/3/2008
AGENCY P "ONt
(A/C, No, E.* 800-745-2409 APPLICANT (First Named Insured)
FAiC,N.,): 630- 665 -7294 TriFvtt Sports
FRANCIS L. DEAN & ASSOCIATES, INC.
1776 S. NAPERVILLE RD., BLDG. B
P.O. BOX 4200
WHEATON, IL 60187
EFFECTIVE DATE
6/13/2008
EXPIRATION DATE
6/13/2009
FCO/PLAN
CODE: SUBCODE:
AGENCY CUSTOMER ID
POLICY NUMBER: WRD 180010
ACCOUNT NUMBER:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
City of El Segundo
Attn: Recreation and Parks Director
350 Main Street, Room 5
El Segundo, CA. 90245 -3813
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS I REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: I BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST
RANK:
NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
X
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGE
LIENHOLDER
EMPLOYEE AS LESSOR
LOCATION:
BUILDING:
VEHICLE:
BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
COMMERCIAL GENERAL LIABILITY
CG 20 11 01 98
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Policyholder /Designation Sports and Recreation Providers Association Purchasing Group/
of Premises
TriFytt Sports
Policy Number WRD 180010 Certificate # AP107754 -00
Name of Person or Organization:
The City of El Segundo, its officers, officials, employees, agents and certified volunteers
350 Main Street, Room 5
El Segundo, CA. 90245 -3813
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Section II — Who Is An Insured is amended to
include as an insured person or organization shown
in the Schedule but only with respect to liability
arising out of the ownership, maintenance or use of
that part of the premises leased to you and shown in
the Schedule and subject to the following additional
exclusions:
1. Structural alteration, new construction or
demolition operations performed by or on
behalf of the person or organization shown in
the Schedule
2. This insurance does not apply to:
a. Any occurrence which takes place after
you cease to be a tenant in that
premises.
CG 20 11 0198 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 0
POLICYHOLDER COPY
SD
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 04 -13 -2009 GROUP:
POLICY NUMBER: 1907158 -2008
CERTIFICATE ID: 2
CERTIFICATE EXPIRES: 08 -01 -2009
08-27- 2008/08 -01 -2009
THE CITY OF EL SEGUNDO SD
350 MAIN ST RM 5
EL SEGUNDO CA 90245 -3813
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
HORIZED REPRESENTATI PRESIDENT
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
TODD, ANDREW JACKSON SD
1500 S ANAHEIM BLVD STE 200
ANAHEIM CA 92805
[B14,SD]
(REV.2-05) PRINTED : 04 -13 -2009