PROOF OF INSURANCE (2015) CLOSEDISAAS -1 OP ID: AZ
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 09110/2014
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
Ka nick Insurance Group I°
-CONTACT
3 3 Box 18ia Drive IA/C_ .Ertl• 517-263-4600 t ck.co m � [A c Not 517- 263 -6658
p P PHONE
CfAMP. Gust B Ba ms ka mTlc c...., ��,.�......._._ .. ............. ._...._ ...
0
Adrian, MI 49221 -7801 pT Tss, dustle bayl� i... m
Tom Fenstemacher _ _ INSURER(S) AFFORDING COVERAGE NAIC 0
INSURER A : Citizens Ins Co of America
.......... _ ...., . --- -------- . .
INSURED Isaac Sports Group INSURER B:
Stu Isaac ...
3419 Wagner Woods Ct. I _ .� ..
NSURER c
Ann Arbor, MI 48103 INSURER 0:
.. .............
INSURER E : �. ,... .. . ..
... .... _ ,_......
INSURER F
COVERAGES CERTIFICATE 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.
w- .. . AtW!k}t'�3�e
INSR • •- .......... TYPE OF INSURANCE ivaw tanm PO�'... .......
OY NUMBER.
......,..,, -.... / r' �LiO Eyy. .. -.. .-
Y YY 7aNMPb dYY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE S
1,000 000
0
L IAr1ULUTY X 07H- A358426
L
A x 17MMCRI }IAh GENrRAIL..
O'FENTEL
08/28/2014 08/28/2015 Pf7FMICFC rF
300,0
.. m CLAIMS -MADE OCCUR
....
MED EXP An one eraon} s
(Any l?
g 5,0
A X EPL ^ 07H- A358426
_
08/28/2014 08/28/2015 PERSONAL
PERSONAL & AD w
� V INJURY „$
_ 1,000,00
�..�.. ..__
GENERAL AGGREGATE $
2,000,00 .
GE14%AGGREGATE LIMIT APPLIES PER.
-I
PRODUCTS COMP /OP AGG $
2,000,00
IL X POIJCY PRO fEL C LoI
EPL $
25,00
AUTOMOBILE LIABILITY
.
COMRINE0 SINGLE I.IhilT
iJlrw.selr +11
1,000_,00
A ANY AUTO 07H- A358426
0812812014 08/2812015 BODILY INJURY (Per person) $
.....
_,._. ALL OWNED '' SCHEDULED
AUTOS AUTOS
_.
BODILY INJURY (Per acadenl) $
NON-OWNED
X X
PROF "('fl3rY UANIA43 $
HIRED AUTOS
... w
IDrh�t....
UMBRELLA LIAB OCCUR
w
E OCC
EACH OCCURRENCE
E
EXCESS LIAR CLAIMS•MADE
AGGREGATE $
m......
OED RETPNTIGN $ _
,g
WORKERS COMPENSATION
X WC STATU• 0TH°
�m
AND EMPLOYERS' LIABILITY
TO LIMITS `
A ANY PROPRIETOR/PARTNER/EXECUTIVE X WDHA407573
0812812014 08/2812015 EL EACHACCIDENT $
500,00,
OFFICERIMEMBER EXCLUDED NIA
F
a-
- °° -
(Mandatory In NHj
E L DISEASE - EA EMPLOYEE $
600,00
ae
n s c!escr
.... ibe under
?TflnN O1' 0 ^RATG9 MNk Imam
__..- ......
E L, DISEASE POLICY LIMIT $
_n.0
500 O
A Professional Liab. 07H- A358426
08128/2014 08128/2015 Limit
1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlllonal Remarks Schedule, If more space Is required)
Certificate holder is listed as additional insured with respects to general
liablity. R waiver of subrogation applies in favor of the certificate
holder in regards to workers compensation.
CERTIFICATE HOLDER
CANCELLATION,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo
THE EXPIRATION DATE THEREOF, NOTICE WILL BE
DELIVERED IN
Y g
ACCORDANCE WITH THE POLICY PROVISIONS,
350 Main St
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
®
�Q.rrw• aa�/t- u,�.�.
®1988 -2010 ACORD CORPORATION. All rights reserved,
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER. 07- A58426 BUSINESSOWNERS
BP 04 48 01 06
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY, .
ADDITIONAL INSURED - DESIGNATED PERSON
OR ORGANIZATION
Name Of Additional Insured Person(s) Or Orclanizatiorbfs),
City of F7_ Segundo, its officers, officials, employees, agents
& volunteers. Recreation Parlc401 Sheldon. St® E1 Segundo, CA 90245
Information rer;luired to complete this Schedule, if not shown above, will be shown in the Declarations
The following is added to Paragraph C. Who Is An
Insured in Section II — Liability:
3, Any person(s) or organization(s) shown in the
Schedule is also an additional insured, 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 omis-
slons or the acts or omissions of those acting on
your behalf in the performance of your ongoing
operations or in connection with your premises
owned by or rented to you. ,
6�
Bi) 04 (IS 01 06 i &) P1!)011"W kl, Iim , 2004 Palo 1 of '1 Cl
Policy Number - 07H-A358426
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
391 1602 '12 11 �2s ""W) fl,", prmnW Jhm Noo I of 1
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
WC 00 03 13
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
different date is inclicateK below.' `l
(The following "attaching clause" need be completed only when this endorsement Is Issued subsequent to preparation of the policy-)
This endorsement, effective on at 12:01 A.M. standard time, forms a part of
(DATE)
PoiicyNo. WDIiA407573 oftheCitizens Insurance (o. of.America
(NAME OF INSURANCE COMPANY)
Issued to Isaac Sports Group
Premium (if any) $
Aulhoke
We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us."
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
City of E1 Segundo, its officers, officials, employees,
agents & volunteers
Recreation Park,401 Sheldon St. E1 Segundo, CA 90245
�-
VVC 00 03 M GopyuIght '1983 NafiorW Coa nd� Apo Cumpmisa icon lo'usuranrce w"tugn 0 M 9