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PROOF OF INSURANCE (2016) CLOSED.Nt C DATE (MM /DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 01/12/2015 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 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 1- 602 -840 -3234 CONTACT NAMe Risk Management Services, Inc, eHOHu � 602- 274 -9138 P.O. Box 32712 Phoenix, AZ 85064 -2712 INSURED LA MIRADA ARMADA USA Swimming, Inc dba USA Swimming RICK SHIPHERD 15806 LANDMARK DRIVE WHITTIER, CA 90604 -3876 info ®theriskneoDl,e.com NATIONAL CAS CO MUTUAL OF OMAHA INS CO COVERAGES CERTIFICATE NUMBER: 42739534 REVISION NUMBER: NAICm# 11991 71412 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. INSR 11S"C-�.UB ............... POLICY EF'F POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER D Y MMPODIYYYY LIMITS INSR A GENERAL LIABILITY X X KKOOOO000048566 -00 01 /01 /1 01/01/16 EACHOCCURRENCE $ 1,000,000 COMMERC AL GENERAL LIABILITY PRFMISFA IF. nnnirtnnral $ 1,000,000 X CLAIMS -MADE f­il OCCUR MED EXP (Anv one person) $ 5,000 X Participant Liability PERSONAL & ADV INJURY $ 1,000,000 X Abuse /Molestation GENERAL AGGREGATE $ NONE . . .................. WWW -. -. GE ;N'L AGGREGATE LIMIT APPLIES .PER: PRODUCTS - COMP /OPAGG $ 2,000,000 ElPOLICY m X ILOC Abuse /Molestation $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ......... ..... BODILY INJURY (Per person) $ ALL OWNED AUTOS _ ........ ............................... BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE ------ - - - - -° HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ ........._............................... A UMBRELLALUIB OCCUR ........ X X XR00000004856700 O1 /O1 /1 01/01/16 EACH OCCURRENCE $ 4,000,000 X EXCESS LIAB CLAIMS -MADE. AGGREGATE $ 4,000,000 X DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS 1 Fa ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. EACH ACCIDENT $ - - -- -- - - - - -- - (Mandatory N in NH) E.L. DISEASE - EA EMPLOYE ' $ If yes, describe under ' DESCRIPTION OF OPERATIONS below E.C. DISEA$E . POLICY LIMIT $ B S Accidont-Modical T5MPSP35054 ax mum LIMIt 25,000 (DESCRIPTION Of OPERATIONS M LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is rogtllircdl Verification of General Liability, Excess Liability & Abuse /Molestation coverage for COVERED ACTIVITIES. Abuse /Molestation Aggregate on the General Liability Policy is $5,000,000. Abuse /Molestation is excluded in the Excess Liability Policy. Excess Medical /Dental Accident coverage provided for participants only. The Certificate Holder is included as Additional Insured per attached ADDITIONAL INSURED ENDORSEMENT EFFECTIVE CERTIFICATE ISSUE DATE„ *30 DAY CANCELLATION PER POLICY PROVISIONS* ICity of El Segundo 'ouncil and Staff City of El Segundo .eredith Petit 1339 Shledon Street El Segundo, CA 90245 CA -RMDA ACORD 25 (2009/09) 42739534 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE USA`.. Ems`, °rsvI ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD National Casualty Company ENDORSEMENT NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF 0R A.M. STANDARD TIME) NAMED INSURED AGENT NO. POLICY NUMBER KKO- 48566 -00 01/01/2015 USA SWIMMING, INC. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSUREDS OWNERS AND /OR LESSOR Vfoing: EMISES, SPONSORS OR CO- PROMOTERS This endorsement modifies insurance provided under the COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional Insured c. This insurance does not apply to liability of any person or organization of the types indicated by an "X" the owners and /or lessors for "bodily injury" or in any boxes shown below, but only with respect to liability "property damage" arising out of any design arising out of your operations: defect or structural maintenance of the prem- ises or loss caused by a premises defect. XC� Owners and /or lessors of the premises leased, rented, or loaned to you, subject to the following With respect to any additional insured included additional exclusions: under this policy, this insurance does not apply to any negligence of such additional insured. a. This insurance applies only to an "occur- rence" which takes place while you are a ten- Sponsors ant in the premises; XX Co- Promoters b. This insurance does not apply to "bodily F] Any individual person(s) or organization(s) listed injury" or "property damage" resulting from below: structural alterations, new construction or demolition operations performed by or on behalf of the owner and /or lessor of the premises; KR -GL -56 (4 -07) AUTHORIZED REPRESENTATIVE Page 1 of 1 DATE Sc P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01 -12 -2015 GROUP: POLICY NUMBER: 1877638 -2014 CERTIFICATE ID: 4 CERTIFICATE EXPIRES: 09 -01 -2015 09 -01- 2014/09 -01 -2015 CITY OF EL SEGUNDO SC 401 SHELDON ST EL SEGUNDO CA 90245 -4013 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 described herein is subject to all the terms, exclusions, and conditions, of such policy. ,e r• r + tea r z Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2015 -01 -12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER INDUSTRY HILLS AQUATICS (A NON- PROFIT PUBLIC BENEFIT CORPORATION) DBA: LA MIRADA ARMADA PO BOX 428 LA MIRADA CA 90637 IREV.7 -2014) PRINTED : 01 -12 -2015 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 1877638 -14 RENEWAL SC 5- 01 -41 -03 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 12, 2015 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING SEPTEMBER 1, 2015 AT 12.01 A.M. AT 12 :01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LA MIRADA ARMADA PO BOX 428 LA MIRADA, CA 90637 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, LA MIRADA ARMADA 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 14, 2015 2570 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 IREV.7 -2014) OLD DP 217 Moore, Cheryl From: Garcia, Angelina Sent: Wednesday, April 15, 2015 10:51 AM To: Ramos, Vina Cc: Moore, Cheryl Subject: RE: La Mirada Armada Auto Yes. Please forward and I will sign. Angelina Garcia From: Ramos, Vina Sent: Wednesday, April 15, 2015 9:49 AM To: Garcia, Angelina Cc: Moore, Cheryl Subject: Fwd: La Mirada Armada Auto Hi Angie, Is the email below sufficient for a statement regarding no auto? Thanks Vina Sent from my iPhone Begin forwarded message: From: "Ramos, Vina" <vrarnos )else urtdo.or r> Date: April 3, 2015 at 7:56:50 AM PDT To: "Garcia, Angelina" AGarcia else Lindo. rg> Subject: La Mirada Armada Auto Hi Angie, Below is LaMirada's statement regarding Business Auto. They do not carry as they don't have any leased autos. Vina Sent from my iPhone Begin forwarded message: From: Richard Shipherd <rshi herd rrisii.com Date: April 3, 2015 at 6:56:14 AM PDT To: "Ramos, Vina" yranios (eis gund± .org> Subject: RE: La Mirada Armada Amendment #1 Vina, We do not have any leased vehicles, or business vehicles of any kind. Thanks for checking with us. Rick Shipherd Armada Swim