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PROOF OF INSURANCE (2016) CLOSEDAte" 40R" CERTIFICATE OF LIABILITY INSUI ANCE DATE (MIN1DDIYYYY) 7/27/2015 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 CONTACI NAME. RPS Bollinger �. WE NN F.0-800-446-531 dl c N i" .7.3-921-2876 101 JFK Parkway EWAI -- Short Hills NJ 07078 ADDRESS sport,,service@rpsins,.com ................ INSURED US Youth Volleyball League 2771 Plaza Del Amo, #808 Torrance CA 90503 INSURER A : INSURER B: INSURER C : INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 744830080 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 _ ...., .... ... .... .... .... ....... IN5R ....... ......... IAOtiL 5"U'e ................... POLICY EFF POLfCY EXP TYPE OF INSURANCE LIMITS LTR i INSR WVD POLICY NUMBER IMMIDD/YYYYI MMlf7:tilYYYY '..A GENERALLIABILITY Y 3602AH028574 8/112015 8/1/2016 EACH OCCURRENCE $1 „000,000 X �AMAGE'YI:Y �t�FlY�t�... COMMERCIAL GENERAL LIABILITY PP -ul- FC rF of CLAIMS -MADE �X OCCUR .. . ,, .,,,.. .. V.� MED EXP _. (Any one oerson) --- _ _$100,000 $5,000 X I.ncl Participant ,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, PERSONAL & ADV INJURY !: $1 „000,000 GENERAL AGGREGATE $3,000000 .... . ............................. G .. ... . . .. EN L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $1,000,000 POLICY' f'6 TY° X � LOC Sexual Abuse /Mol $l mil /$2mil A AUTOMOBILE LIABILITY 3602AH028574 8I1I2015 8/1/2016 !Fa annidanll .�., ._w ..:.. ....,. 1 OOOi000 ., .....,.. .... ANY AUTO BODI LY INJURY RY ( Per Personon) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS _..... X NON -OWNED IX P'R'OPI:RTw DAM'AGE..... $ HIREDAUTOS AUTOS (PO,r�6C �1;)au)4) '.. UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- '.. OTH- IAND EMPLOYERS' LIABILITY YIN TnRY UK175 FR ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? (Mandatory in NH) NIA — ---.......... E,L DISEASE - EA EMPLOYEE, $ If es, describe under ,......._ _ ..-. ,.,.,. ._,..,.,_, .............. !. DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT $ B Accident Insurance 4102AH028573 8/1/2015 8/1/2016 Med Max: $25,000 Full Excess Ded: $100 DESCRIPTION OF OPERATIONS / 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 for sponsored /supervised activities of the named insured. Group Code: 3602AH028574 CERTIFICATE CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo Recreation and Parks Dept ACCORDANCE WITH THE POLICY PROVISIONS. 401 Sheldon Street El Segundo CA 90245 AUTH RIZ'EDREPR'ESE�NTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD kv\-' 1. POLICY NUMBER: 3602AH028574 - 11 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED EO - MANAGERS OR LESSORS OF t This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE City of El Segundo, its officers, officials, employees, agents and are named as an additional 2. Name of Person or Organization (Additional Insured): 3. Additional Premium: (If no entry appears above, the information required to complete this endorsement will be shown In the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to This insurance does not apply to: Include as an insured the person or organization shown in the Schedule but only with -4a,— 1. Any "occurrence" which takes place after you liabillit �1�00u the owner p, or cease to be a tenant in that premises. uo e ndshown a an subject to the followw'ing' 2. Structural alterations, new construction or additional exclusions: demolition operations p performed by or on behalf of the person or organization shown In the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 C3 United States Youth Volleyball League Dear Jesse Bobbett: The USYVL does not own any business vehicles, therefore we are asking that the automobile liability insurance be removed from our requirements. With regards to Workers compensation insurance, El Segundo USYVL is a volunteer organization and does not pay its coaches. Thank you, wrl Randy Sapoznik 2771 Plaza Del Amo • Suite 808 • Torrance • CA 90503 Phone 310 - 212 -7008 • Toll Free 1- 888 - 988 -7985 • Fax 310 - 212 -7182 • www.usyvl.org Business Automobile Insurance Date: 3/17/2015 United States Youth Volleyball League (USVYL) is a 501 c -(3) organization and doesn't own or lease any Business Automobiles. Randy Sapoznik Firm M9 Request for Taxpayer Give Form to the (Rev. December Identification Number and Certification requester. Do not the mtanf of tits Tmasury send to the IRS. I�atemdi RWWue service 1 Name (as shown on your income tax return;). Name Is roqulted on this line; do not leave this line blank. United States Youth Volleyball League C` 2 Business roner'di'sragarded entity name, If different from alxwe m 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to ❑ Indlvidual/sols proprietor or C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/ostate LLC cwtalctlonsities,� lr3 ivldusls; a" on single - member ❑ Umited liability company. Enter the tax classification (C-C corporation, S=S corporation, P=parb shlp) ► Exempt payee code (d any) yy Note. For a single- member LLC that is dIsnVamled, do not check LLC; check the appropriate box In the Ilne a bove for Exemption from FATCA reporting tho tax classlfication of the sin& •mambsr owner. code (if any) 1 — 0 0ther (am fnstrt, dons) 10. to a. u.sl 5 Address (number, street, and apt. or suite no.) s name and address (optional) 2771 Plaza Del Arno, Suite 808 6 City, state, and ZJP code 'Torrance, CA 90503 7 List account num be(s) here (optional) Fitter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it (s your employer Identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this forth (if any) indicating that I am exempt from FATCA reporting is correct. Certiflostlon Instructions. You must cross out Item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement ORAL and generally, payments other than Interest and dividends„ you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 3, Sign signstum of Here U.S. person ► Dab P. General Instructions Section references are to the Intemal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Forth W -9 (such as legislation enacted after we release It) Is at www.1m.gov 1fw9. Purpose of Form An individual or entity (Form W -9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social sectirlty number ($$I!f), Individual taxpayer identification number (ITIN), adoption taxpayer Iderftlficatkin number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns Include, but are not limited to, the following: • Form 1099 4NT pnterest earned or paid) • Form 1099 -Div (dividends, Including those from stocks or mutual funds) • Form 1099 -MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099 -B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-( (merchant card and third party network transactions) • Form 1096 (home mortgage Interest), 1098 -E (student loan Interest), 1098 -T (tuldon) • Form 1099-C (canceled debt) • Form 1099 -A (acquisition or abandonment of secured property) Use Form W -9 only If you are a U.S. person (including a resident alien), to provide your correct TIN. Of you do not Mum Form W -9 to the sequester with a TIN, you ntlght be subject to bac*vp Wthholding 'Sao What is backup w4fthofdfng7 on page 2� By signing the filled -out form, you: 1. re Certify that the TIN you are giving is correct (or you a waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim examption from backup withholding If you eats a U.S. exempt paymee. If applicable, you area also cortifyiarg that as a U.u. person, your allocatrle share of any partnership Income from a U S. trade or bLisirms is not subject to the withholding tax on foreign partners' shere of offectivaly connectod Income, and 4, Csrtlfy fhtat FATCA codo(s) entered on this form (if any) Indicating that you we exempt from the FATCA reporting, Is correct. Sao 144hat 1's F"AMA reporting? on page 2 for further lnfoon salon.. Cat. No. 10231 X Form vii -9 (Rev. 12 -2014)