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PROOF OF INSURANCE (2015) CLOSEDoats ' CERTIFICATE OF LIABILITY INSURANCE DATE,MMIDDIYYYY) 1/2312015 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(les) 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 Willis insurance Services. of Georgia, Inc. NAME: NAIC q www.Wllls.com INSURER A : INSURED INSURER 8: California State Soccer Association — South (Cal South "youth) INSURERS: 1029 South Placentia Avenue INSURER D: Fullerton CA 92831 COVERAGES CERTIFICATE NUMBER: 7,41ARQ9,q 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. IL7r TYPE OF INSURANCE ucn wvn POL_ICYNUMBER, 'Mi?GYI'PYFV' ,jp:ppNOAP m'rr.. LIMITS 'A ,�+ COMMERCIAL GENERAL LIABILITY �/ �/ PHPK1210843 9/1/2014 9/1/2015 EACH OCCURRENCE s 1,000,000 I✓ - .... ._ ...... 100,000 CLAIMS -MADE OCCUR PREMiSCS(Fat%gaLncet S MED EXP (Anv one person) s 5,000` Alhietfc PartW ant Leoal Llab. PERSONAL dADVINJURY _ $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 J" POLICY [:] 90R F� LOC PRODUCTS- C9ME2EAGG S 3,000,000 OTHER: Abuse A Molestation S 1.000.00qPer0cc AUTOMOBILE LIABILITY OMBINED SIN LE LtlW1 .ila_a0amnt) _ ANY AUTO BODILY INJURY (Per person) S ALL OWNED SCHEDULED AUTOS AUTOS I BODILY INJURY (Par accident) Ys _ NON -OWNED PROPERTY DAMAGGE s HIRED AUTOS AUTOS A 5 A ,/ '.. UMBRELLALIAB ,/ OCCUR PHUB468948 91112014 9/1/2015 EACH OCCURRENCE S 2.000.11 '... EXCESS LIAB CLAIMS -MADE AGGREGATE S 2,000,000 ncn RETENTIONS s WORKERS COMPENSATION PER OTH- I AND EMPLOYERS' LIABILITY YIN $TA?UTE ER E „L. EACH ACCIDENT S ANY PROPRIETORIPARTNERIEXECUTIVE r-7 OFFICER/MEMBER EXCLUDED? N / A —° ------- (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ II es, dos�'xlbe under D SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) LEAGUE: 0425 LEAGUE NAME: South Bay Force FC ADDRESS: PO Box 7000 -879 Redondo Beach CA 90277 -8710 •Med Pay ap dies for spectators only, Certificate Holder Is an additional insured as respects CalSouth Youth sanctioned events only where required. 0425 :South a Force d.b.a LA Galaxy South Bay The Clty of EI egundo, its officials, employes are named as additionatly insured With respect to General Liability. General liabifty is primary. Waivers of subrogation applies to the workers compensation In favor or the city of EI Segundo U1440 R0 hSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Et_ Segundo Recreation and Parks �, ACCORDANCE WITH THE POLICY PROVISIONS. 380 Main Sireet �✓� w El Segundo CA 90245 AUTHORIZED REPRESENTATIVE � + Terry Michelitch ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CBET' NO.: 23),6 J23 Ti. Sum e.1 1/23/2015 3:28:42 PM (EST) F tv 1 f 2 Ttlis certi icate cartSe r� and supersedes ALL prevaro- ply issued certificates. SOUTH -6 OP ID: LM ,�►coRO' CERTIFICATE OF LIABILITY INSURANCE DATE 01 12 812 01 YY) 01/28/2015 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 terns 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 endomement(s). PRODUCER Dodge Insurance Services Inc. DBA: Arroyo Insurance Services 3510 Torrance Blvd., Suite 305 Torrance, CA 80503 Robert J. Kelly INSURED South Bay Force Inc dba: L A Galaxy South Bay P O Box 7000.879 Redondo Beach, CA 90277 N.'4'A " NA: Robert Kelly PHONE ar _....... IA(C No EYn,310- 356 -8206 ADDROsS�robertl_r ro�roins.com INSURER[SI AFFORDING COVERAGE INSURER State Compensation Ins Fund . ............_....._ �_. ._ .......... _ . ........ ...__...__...._......... INSURER B: INSURER C : ....._ ................................ ..__.,.....,_..._�....�...,...� INSURER D : .._..._....._........_..._._ .... ...............:..........:._.. 310- 316 -1825 NAIL 9 35076 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. LTR. TYPE OF INSURANCE iuen unm POLICY NUMBER MMfiDDfyY'"P'W' ) POLICYEXP MMdOt] /YYylf'.. LIMITS ......... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 7_1 CLAIMS ffAMAGE'TO R "" -MADE OCCUR PRFMISFS (Ea ocrixrsnra. S MED EXP (Any one person) $ PERSONAL BADV INJURY S GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE S PRO- POLICY JECT ❑ LOC PRODUCTS- COMP/OPAGG - ,._.,........ S OTA"IER: S .. ......... AUTOMOBILE LIABILITY I N L MI' 0 ecrideo S ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S NON -OWNED PRMATY DANWyff— $ HIRED AUTOS AUTOS (Per arcNden4 S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S .........m...... DED RETENTIONS S W'ORHERSCONIIPENSATION X AND EMPLOYERS'ILIABILRY /�N STATUTE ERry A ANY PROPRIETO�RtPARTNER/F.Jt'ECUTNE X 190341014 07/01/2014 0710112015 E.LEACHACCIDENT S 1.000.00 OFF ICERWEMBER EXCLUDED? � N / A Nn NI ¢ OYEE, E.L. DISEASE - EA EMPLOYEE $ 1,000,00 yy ESCRIPTI N under PERATIONS ;ow E „L DISEASE - POLICY LIMIT S 1.000.00 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Waiver of Subrogation in favor of the City of El Segundo, as per attached. CERTIFICATE HOLDER CANCELLATION CT'ESOIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Recreation & Parks Department 401 Sheldon Street 1 AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 VillD-0— ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD PHPK1210843 California State Soccer Association — South (Cal South Youth) 1/23/2015 PI- AS-010 (04/04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED: OWNERS AND / OR LESSORS OF PREMISES, LESSORS OF LEASED EQUIPMENT, SPONSORS OR CO- PROMOTERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This policy is amended to include as an additional Insured any person or organization of the types designated below, but only with respect to liability arising out of your operations: 1. Owners and / or lessors of the premises leased, rented, or loaned to you, subject to the following additional exclusions: a. This insurance applies only to an "occurrence" which takes place while you are a tenant In the premises; b. This insurance does not apply to "bodily injury" or "property damage" resulting from structural alterations, new construction or demolition operations performed by or on behalf of the owner and / or lessor of the premises; c. This insurance does not apply to liability of the owners and / or lessors for "bodily injury" or "property damage" arising out of any design defect or structural maintenance of the premises or loss caused by a premises defecL With respect to any additional insured included under this policy, this insurance does not apply to the sole negligence of such additional insured. 2. Lessor of Leased Equipment, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s) subject to the following additional exclusions: a. This insurance does not apply to any 'occurrence" which takes place after the equipment lease expires. 3. Sponsors 4. Co- Promoters City of El Segundo Attn: EL Sequndo Recreation and Parks 350 Main Street El Segundo CA 90245 Page 1 of 1 CKgT HO.: 2346 p23 Tim Summ "k 1/y/2015 3:28A2 PM (EST) Page 2 f 2 Tries certl icate cancels and supersedes ALL previously issued certificates,. �Y er r HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SOUTH BAY FORCE JOHN MOODY PO BOX 7000 -879 REDONDO BEACH, ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 05 1903410 -14 RENEWAL SC, 5- 53 -52 -70 ` PAGE 1 OF 1� EFFECTIVE JANUARY 26, 2015 AT 12.01 A.M..'' AND EXPIRING JULY 1, 2015 AT 12.01 A.M. FC INC CA 90277 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, SOUTH BAY FORCE FC 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: JANUARY 28, 2015 2570 AUTHORIZED REPRESE IV'E PRESIDENT AND CEO SCIF FORM 10217 (REV.7 -2014) OLD DP 217 Shilling, Mona From: Shilling, Mona Sent: Tuesday, March 03, 2015 9:06 AM To: Moore, Cheryl Subject: FW: LA Galaxy insurance Attachments: 3 -2 -15 LA Galaxy contract packet.pdf Cheryl, Attached is an agreement that is read for processing. I already printed it. We'll review when we get together, Mona S From: Ramos, Vina Sent: Monday, March 02, 2015 10:17 AM To: Shilling, Mona Cc: Bobbett, Jesse; Green, Shawn; Garcia, Angelina Subject: RE: LA Galaxy insurance Good morning Mona, Attached is the packet for LA Galaxy. Please proceed with the signature process and let me know if you need anything else. First session starts on 4/1/15. Thank you, Vina Ramos Sr. Administrative Analyst Recreation and Parks Department 310 - 524 -2882 From: Garcia, Angelina Sent: Tuesday, February 24, 2015 1:06 PM To: Ramos, Vina Cc: Bobbett, Jesse; Green, Shawn; Shilling, Mona Subject: RE: LA Galaxy insurance Approved. Angelina Garcia From: Ramos, Vina Sent: Tuesday, February 24, 2015 12:42 PM To: Garcia, Angelina Cc: Bobbett, Jesse; Green, Shawn Subject: FW: LA Galaxy insurance Good afternoon Angie, Please advise if you accept attached insurance for a soccer instructor. Thanks, Vina Ramos Sr. Administrative Analyst Recreation and Parks Department 310 - 524 -2882 From: Ramos, Vina Sent: Thursday, February 05, 2015 3:29 PM To: Garcia, Angelina Cc: Green, Shawn; Bobbett, Jesse Subject: LA Galaxy insurance Hi Angie, Attached are insurance documents for South Bay Force DBA LA Galaxy. Please review and let me know if you need anything else. They will sign an Instructor Agreement. Thank you, Vina Ramos Sr. Administrative Analyst Recreation and Parks Department 310 - 524 -2882