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PROOF OF INSURANCE (2014) CLOSEDUKINT -2 OP ID: WK
A DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 03108113
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
800- 526 -1379 ncaAkLMLCT
Bollin er, Inc. PHONE ..........._. .... FAX
101 JFK Parkway 973- 921 -2876 IA(
MAIk, .. ,_... .. .._.._.,,.
Short Hills, NJ 07078 -5000 E E MAIL s°
John T. Splotta �� _ .__ ... ..................
INSURER A: Markel Insurance
INSURED UK International Soccer Camps,
INSURER B:
Inc.URER
THIS
PO Box 1838
C,
INS R C '
Redlands, CA 92373
JNSURER D_
INSURER E:
THE INSURED
NAMED ABOVE FOR THE POLICY PERIOD
'.. INSURER F
COVERAGES CE'RTIF'ICATE NUMBER:
REVISION NUMBER:
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.
NSR
ILTR
_
.
& L�FF`
P Yt;l'EXP
" .� _ _.._. _ .
.�.......
TYPE OF INSURANCE
POLICY NUMBER
IM,M1DDIYYYYI .
MMIDDIYYYY
LIMITS
GENERAL
LIABILITY
EACH OCCURRENCE
$ 1,000,00
A
X
COMMERCXAL GENERAL LIABNILLIY
X
8602AH238111
02101/13
02/01/14
PREJMI�� n �nce)
$ 100,00
CLAIMS -MADE � OCCUR
_ .., -.
MED EXP (Any one person)
$ _ 5,00
_
r X
Inc, Participants
.. ..... ,,. , ".,...�... ,.,a..,.,..., w,........,..
PERSONAL BADV INJURY
....$.
$ 1,000,_00
...
-
GENERAL AGGREGATE
3,000,000
_..
GEN
1. Ar',aGR:EGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ 1,000,000
7n
AUTOMOBILE
LIABILITY
COMBNEIJ SINGLE LIMIT
//Ea acrAdent
$
ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS AUTOS
NON -OWNED
PROPERTY DAMAGE
$
HIRED AUTOS AUTOS
(Per accident)
UMBRELLA LIAR OCCUR
EACH OCCURRENCE
$
......._..DED
EXCESS LIAB CLAIMS -MADE
.._ - ...... ........................
AGGREGATE
$
.---......-. �... .............................�
RETENTION.$
WORKERS COMPENSATION
OTH-
AND EMPLOYERS' LIABILITY YIN
VC
..- L—E
ANY PROPRIETORIPARTNERIEXECUTIVE
E L.. EACH ACCIDENT
$
OFFICERIMEMBER EXCLUDED? ❑ NIA
(Mandatory In NH)
E.L.. DISEASE - EA EMPLOYEE S
..m.... -- -..m " "-E_
1
.�...�..
DESCRIPTION OF OPERATIONS below
ASE - POLICY LIMIT
E� DISEASE
$
A Accident Insurance 4102AH2381 10 02/01113 02/01/14
Med Max:
100,00
Full Excess
Ded:
50
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
The certificate holder is named as an additional insured under the liability
policy. Coverage is provided under this policy only for sponsored /supervised
activities of the named insured for which a premium has been paid.
L_
ELSEG1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CI of El Se THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Clerk Segundo �,� ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St AUTHORIZED REPRESENTATIVE
El Segundo, CA 90248
©1988 -2010 ACORD CORPORATION. All rights reserved,
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
ATTACHED TO AND FORMING PART OF COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 8502AH238111 - 11
Markel Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
THIS ENDORSEMENT WILL ONLY BECOME EFFECTIVE UPON THE ISSUANCE OF A
CERTIFICATE OF INSURANCE ISSUED BY AN AUTHORIZED REPRESENTATIVE FOR THE
COMPANY. THIS CERTIFICATE MUST BE ON FILE WITH THE COMPANY AND THE
INFORMATION REQUIRED TO COMPLETE THIS ENDORSEMENT WILL BE SHOWN IN THE
CERTIFICATE OF INSURANCE APPLICABLE TO THIS ENDORSEMENT.
WHO IS AN INSURED (Section II) is amended to include as an additional insured the person or
organization shown in the Schedule as an insured but only with respect to the following
specified liability:
Managers or Lessors of Premises
Liability arising out of the ownership, maintenance or use of that part of the premises
leased to you and shown in the Schedule, subject to the following additional exclusions:
This insurance does not apply to:
Any "occurrence" which takes place after you cease to be a tenant in that
premises; and
2. Structural alterations, new construction or demolition operations performed by
or on behalf of the person or organization shown in the Schedule.
11. Grantor of Franchise
Liability as grantor of a franchise to you.
III. Lessors of Leased Equipment
Liability for "bodily injury ", "property damage" or "personal and advertising injury"
caused, in whole of in part, by your maintenance, operation or use of equipment
leased to you by such person(s) or organization(s).
With respect to the insurance afforded to these additional insureds, this insurance
does not apply to any "occurence" which takes place after the equipment lease expires,.
All other terms and conditions remain the same..
MGL165 (7/05) Page 1 of 1
CERTHOLDER COPY
SJ
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 04 -17 -2013
CITY OF EL SEGUNDO Si
DEPT OF BUILDING & SAFETY
300 E PINE AVE
EL SEGUNDO CA 90245 -3056
GROUP:
POLICY NUMBER: 1890817 -2013
CERTIFICATE ID: 6
CERTIFICATE EXPIRES: 04 -01 -2014
04 -01- 2013/04 -01 -2014
THIS CERTIFICATE SUPERSEDES AND CORRECTS
CERTIFICATE # 5 DATED 04 -17 -2013
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 escribed herein is subject to all the terms, exclusions, and conditions, of such policy.
v- .
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - ALSOP, NICK VP,SEC - EXCLUDED.
ENDORSEMENT #1600 - GAMBLE, GARY PRES,TRES - EXCLUDED.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2013 -04 -17 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF EL SEGUNDO
EMPLOYER
UK INTERNATIONAL SOCCER CAMPS INC Sd
PO BOX 1838
REDLANDS CA 92373
[SAZ,CS]
(REV. 1-201M PRINTED : 04 -17 -2013
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
HOME OFFICE
SAN FRANCISCO EFFECTIVE APRIL 1, 2013 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 1, 2014 AT 12.01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
UK INTERNATIONAL SOCCER CAMPS INC
PO BOX 1838
REDLANDS, CA 92373
1890817 -13
RENEWAL
SJ
4- 24 -57 -59
PAGE 1 OF
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING:
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF EL SEGUNDO
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY:
UK INTERNATIONAL SOCCER CAMPS INC
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: MAY 3, 2013 /
AUTHORIZED REPRESENW `I'VE PRESIDENT AND CEO
SCIF FORM 10217 (REV,1-2012)
1
2570
OLD DP 217
WAIVER OF SUBROGATION NOTICE
Enclosed is your copy of a certificate of insurance on which the certificate holder
required a waiver of subrogation:
1. Please be advised that a waiver of subrogation requires that a 3% surcharge
will be applied by State Fund ONLY to the premium assessed on the payroll
of your employees earned while engaged in work for that certificate holder
who requested the waiver. (Note: if you have no employee payroll on that job,
then there is no charge.)
2. To apply the 3% surcharge, you must also agree to maintain accurately
segregated payroll records for employees engaged in work on job /s for the
certificate holder who has the waiver. The payroll records are subject to
verification by an auditor.
Example:
Payroll for job: $5,000.00
Sample Rate: 13.30%
Regular Premium equals: $ 665.00
Surcharge: 3.00%
Additional Waiver charge: $ 19.95
Total premium equals $ 684.95 (665.00 + 19.95)