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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)