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PROOF OF INSURANCE (2015) CLOSEDA "R DATE (MM /DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 5/23/2014 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 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 CITY SECURITIES CORPORATION NAME: 8900 KEYSTONE XING STE 300 PHONE N Ext : 800-800-2489 I� N� . 317- 972 -7142 PO BOX 44992 (PAYMENTS ONLY) E -MAIL INDIANAPOLIS, IN 46240 -4698 ADDRESS: 800 - 800 -2489 INSURERS) AFFORDING COVERAGE NAIC # INSURERA: United States Fire Insurance 21113 _ ...... ................._._.__......_. �.............._.r INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B IT :S PART ICIPAI ING ME::ME IE:RS: _ .............�,. INSURERC : T Clay Evans Southern California Aquatics INSURER P.O. Box 66425 ; Los Angeles, CA 90066 INSURERE INSURER F : ('OVFRAhFS CFRTIFICATF NIIIIIII IISP1F9A91 RFVISIf)N AIIIRARFR^ 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. INS LTR TYPE OF INSURANCE ADDL a UBR INSR 'wVD POLICY NUMBER POLICY EFF MMIDDIYYYY) POLICY EXP (MMIDDIYYYY ) LIMITS GENERAL LIABILITY GENIERALAGGRE'GA'T"E:. $2,000,000.00 PRODUCTS - COMP /OP AGG $2,000,000,00 X COMMERCIAL GENERAL LIABILITY m n r;LevMa- I.nAr:/E •.�.. PERSONAL &ADV INJURY $1,000,000.00 A e.. (occuR X 05/18/2014 05/1812015 °NCE SRPGP- 101 -0414 12:01 AM 12:01 AM EACHOCCURRE ......... ............CU..-.............. $1000,000.00 FIRE DAMAGE (Any one fire) $300,000,.00 f3r:: ".IV'L AG('TFiEC.;A'YE uIUBT APF ^ur:::F> PER : MED EXP (Any one person) $5,000.00 PRO- X POLICY JECT LOG AUTOMOBILE LIABILITY coMBINED SINGLE. LIMIT Ea acridenkl $ ANYAUTD BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accidenk ( ) $ HIRED AUTO NON -OWNED PROPERTY DAMAGE. AUTOS PPr �rrkiznt $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE. AGGREGATE: $ DED RETENTION .S EACH OCCURRENCE $ GENERAL.. AGGREGA.I..E- $ EACH OCCURRENCE. $ GENERAL A( GRE GAF $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Youth Camp The certificate holder is added as additional insured but only with respect to liability arising out of operations of the named insured during the policy period. Coverage is Primary and Non - Contributory. A Waiver of Subrogation applies. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 Main Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Francis L. bean ACORD 25 (2010106) © 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Policy Number: SRPGP- 101- 0414/USP152421 Insured: T Clay Evans Southern California Aquatics This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section II - WHO IS AN INSURED is amended to include as an insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions of the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. To the extent that any of the additional insureds named herein are liable for occurrences arising out of the named insured's negligent acts or omissions, the insurance afforded to the additional insureds under this endorsement is primary insurance over any other valid or collectible insurance which the additional insureds may have with respect to loss under any of the listed policies. Other insurance of any additional insured applicable to loss is non- contributory and excess over the coverage provided by this endorsement, and the amount of the company's liability under this policy shall not be reduced by the existence of such other insurance. CG 20 26 07 04 C ISO Properties, Inc., 2004 Page 1 of 1 0 COMMERCIAL GENERAL LIABILITY CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policyholder T Clay Evans Southern California Aquatics Policy Number SRPGP- 101- 0414/USP152421 Designation of Premises; City of El Segundo 350 Main Street El Segundo, CA 9( 1. Designation of Premises (Part Leased to You): Refer to the Schedule of Additional Insureds shown on the Member Certificate of Insurance. 2. Name of Person or Organization (Additional Insured): Refer to the Schedule of Additional Insureds shown on the Member Certificate of Insurance. 3. Additional Premium: (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the 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: This insurance does not apply to: 1. Any "occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. To the extent that any of the additional insureds named herein are liable for occurrences arising out of the named insured's negligent acts or omissions, the insurance afforded to the additional insureds under this endorsement is primary insurance over any other valid or collectible insurance which the additional insureds may have with respect to loss under any of the listed policies. Other insurance of any additional insured applicable to loss is non - contributory and excess over the coverage provided by this endorsement, and the amount of the company's liability under this policy shall not be reduced by the existence of such other insurance. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 ❑ COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: Policy Number: SRPGAPM- 1014/USP152421 Insured: T Clay Evans Southern California Aquatics COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of El Segundo 350 Main Street El Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV —Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 06 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ Page 1 of 1 Ramos, Vina From: Clay Evans [clay @swim.net] Sent: Friday, October 10, 2014 4:14 PM To: Ramos, Vina Subject: Auto Insurance Dear El Segundo City, c/o Ramos, Vina The SCAQ Swim Club does not have a company /team car. Therefore we have no auto insurance needs. Thank you, Clay Evans Director SCAQ Swim Club 10/13/2014 A DATE (MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 10,/912014 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 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 endorsernent(si. PRODUCER Lisa Anderson Shaw Moses Mendenhall and Associates PHONE (626)799-7813 7 FAX 99-8784 625 Fair Oaks E -il Suite 158 INSURER S. AFFORDING COVERAGE NAIC # South Pasadena CA 91030 INSURERA:State Compensation Ins Fund INSURED INSURER 8: Southern California Aquatics Swim Club INSURER C : 3646 Barry Avenue INSURER D: ENDORSEMENT AGREEMENT - WAIVER OF SUBROGATION 9093695 -14 NEW SC 8- 74 -63 -10 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE SEPTEMBER 26, 2014 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING MARCH 26, 2015 AT 12.01 A.M. AT 1201 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SOUTHERN CALIFORNIA AQUATICS S PO BOX 6'6425 LOS ANGELES, CA 90066 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, THE CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, SOUTHERN CALIFORNIA AQUATICS SWI IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN'WORK FOR THE ABOVE EMPLOYER, IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL- BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, 'AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: SEPTEMBER 30, 2014 2570 AUTIOCIED REPRE6EIT VVE PRESIDENT AND CEO SCIF FORM 10217 IREV,7.20141 OLD OF 217