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PROOF OF INSURANCE (2015) CLOSEDDATE (MM/DDIYYYY) A,iC"RO CERTIFICATE OF LIABILITY INSURANCE 09/11/2014 F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS HIS CERTIFICATE IS ISSUED AS A MATTER 0 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CATE, OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFI E HOLDER. EN,TATIVE OR PRODUCER, AND THE CERTIFICAT ndor ed. if SUBROGATION IS WAIVED, subject to REPRESI - 11 11 1 I'll , - I NSURED, the p icy(jes) must be t confer rights to the IMPORTANT: if the certificate holder s all iIDDJ I 1014AL orsement. A stat ent on this certificate does no the terms and conditions of the policy, certain policies may require an end em certificate holder in lieu Of such endorsement(s) N A Compa 0 PcFi-I ��s �� �y NE Sterling Agency Insurance Services E., tL INSUR _F ale Ira C dale Insu INSURED Sorgiuuoonoa DBA: Jaguar Tennis Academy REVISION NUMBER: R' BOVE -FOR THE POLICY FERIOD 3VERAGES 7' L ER DOCUMENT WITH RESPEC"r To WHICH THIS THIS 15 TO CERIIFY THA OR CONDITION OF ANY CONTRACT OR' OTH EIN �S SUBJECT 10 ALL THE TERMS, INDIC ED, NO'TWITHST RANCE AFTORDED BY THE POLICIES DESCRIBED HER CERTIFK,AtE MAY BE IS K);VYN MAY HAVE BEEN REDUCED BY PAID CLAIMS, in AND C10NDI` EFF- 1P;6Gd-Vi-wEXP"'_ LIMITS EXCLUSIONS MWI)DIYYYY isR TYPE OF INSURANCE TR COMMERCIAL GENERAL LIABILITY x CPS2051988 A CLAIMS-MADE OCCUR POLICY PRO AUTOMOBILE LIABILITY ANY AUTO SCHEDULED ALL OWNED AUTOS AUFOS UTOS NON-OWNED HIRED AUTOS AUTOS ME, �LALIAB OCCUR WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ *'^ ww under DESCRIPTION OF OPERATIONS I LOCATIONS I VEHIC itional Remarks Schedule, may be attached it more space is required) u The City of El Segundo, i fficers, SHOULD AN OF THE A E DESCRIBED POLICIES BE CANCELLED BEFORE 4L P E POLICY P s ", as Additional insured AUfOgL4 0 eP t�NTATIVe 401 Sheldon Avenue A El Segundo, CA 902 J J @ 1988-2014 AUYl-- tATAON, All rights reserved- The ACORD name and logo are registered marks of ACOR6 ACORD 25 (2014/01) ENERAL AGGREGATE $ 1,000,000 COMP/OP AGG $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHIC itional Remarks Schedule, may be attached it more space is required) u The City of El Segundo, i fficers, SHOULD AN OF THE A E DESCRIBED POLICIES BE CANCELLED BEFORE 4L P E POLICY P s ", as Additional insured AUfOgL4 0 eP t�NTATIVe 401 Sheldon Avenue A El Segundo, CA 902 J J @ 1988-2014 AUYl-- tATAON, All rights reserved- The ACORD name and logo are registered marks of ACOR6 ACORD 25 (2014/01) CPS2951988- COMMERCIAL GENERAL LIABILITY POLICY NUMBER: CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES R CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: ` COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured °Person(s) City of El Segundo, its officers, agents and volunteers n required to Location And Description R on Of Ccrnpleted Opera- tions s Recreation Park 401 Sheldon St. El Segundo, CA. 90245 mm— w hedulp if not shown above, will b shown in the scare sore. this Sc Section tI Who Is An insured is amended 16 include as an additional insured the persons) or organi; - tion(s) shown in the Schedule„ but only with respect to liability for "bodily injury " or "property damage " caused, in whole or in part, by "your work " at the location desig- nated and described in the schedule of this endorse- nzent performed rot that additional insured and inctuded in the "products - completed operations hazard CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY Ni. %4BER: CPS2051988 COMMERCIAL GENERAL LIABILITY CG 201Q 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - O NERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATIOR , This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Add`-oilonal Insured Person(s) stir Oroanizationdsi. CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENT AND VOLUNTEERS to complete this Schedule, if A. Section 11 — Wjio Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only w th respect to liability for " "bodily injury." "property . damage" or "personal and advertisin injury"' causer, In whole or in part„ by: 9. Your acts or omissions; or :. 2. The acts or omissions of those aciing on your behalf; in the performance of your ongoing operations for the additional insured(s) at the locaiion(s) desig- nated above. Covered will be shown in the Declarations. B. With respect to the insurance afforded to these additional insureds, the fallowing additional exQlu- lions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1- All work, including materials, parts or equip- ment furnished in connection with such work. on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. 1 hat portion of "your work.' out of which the injury or•'da€nage arises has teen put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. .CG 20 10 07 04 O ISO. Properties, Inc., 2004 Page 'I of 1 13 Coverage Summary https: // service. geico. com/ insite /simplifiedCoverageSummary.xh,,. Coverage Summary Policy Number: 4277475929 Policy Period: 08/13/2014 to 02/13/2015 Your current 6 month premium: $527.30 These coverages apply across all vehicles *For specific details, consult your policy contra . For Others The below coverages pay out to other parties if the accident is your fault. Bodily Injury Liability $92.00 $15,000 per person /$30,000 per occurrence Property Damage Liability $146.00 $25,000 per occurrence For You The below coverages pay out to you and your passengers. Uninsured Motorist & Underinsured Motorist $21.20 $15,000 per person /$30,000 per occurrence 1 of 2 9/15/2014 11:04 AM Coverage Summary Vehicle total 6 month premium $116.10 2000 FORD F250 SPDTY Uninsured Motorist Property Damage $3.80 $3,500 Recommendations for you; Comprehensive Add with a $250 Ded. for only $24.60 per 6 months https: // service. geico. com/ insite/ simplifiedCoverageSummary.xh.... Vehicle total 6 month premium: $411.20 2007 M BENZ R320 Comprehensive $55.90 Deductible: $500 Collision $198.40 Deductible: $500 Emergency Road Service $10.00 Full Coverage Vehicle Recommendations for you: Rental Reimbursement Add for only $26.80 per 6 months 2 of 2 9/15/2014 11:04 AM T0: City of El Segundo SUBJECT: Sole Proprietor /Partnership /Closely Held Corporation With No Employees Please let this memorandum notify the City of El Segundo that I am a: Sole Proprietor and do not have any employees whose employment requires me to carry workers' compensation insurance. All my future employees will be employed as independent contractors. Therefore, I do not carry worker's compensation insurance coverage. Contractor's Signature p Printed Name of Contractor �� � ��"�/ ����� �� � ��r,. �� /e- �5 Date 3-- Is- —