Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
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