PROOF OF INSURANCE (2016) CLOSED I I
THIS CERTIFICATE IS ISSUED ASA 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 IN AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 I CONTACT
rtAME:
BOLLINGER,Inc. PHONE rAx
101 JFK PARKWAY I LAX.rlo.Ext):800-"Sd 531 t A1C.rlaw.:87'0.8'21.26'78
SHORT HILLS,NJ 07078 16MNL
PHONE:1-800-440-5311 FAX:873.821-2676 ADMU:
INSURER(S)AFFOIIDIIIG COVERAGE NAIC a
I INAURMA:Market lnsuranceCompanar
INSURED I rNSUrtErta:
US Lacrosse,Inc. ,h
ealrtultEErr o
113 west University Parkway �
Baltimore lvm 21210
Re:EI Segundo Lacrosse m Wrung E:
INiUM►:
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 RECUI'REMENT„TERM OR CONOIT04 OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THM CERTIFICATE AIRY BE ISSUED
OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIE DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C'LAIMIS.
LTRLT . OF INSURANCE ADDL' wen POLICY NUMBER Yr:►"r` KNXYVW LIMITS
TYPE maeR VWO Immmorn-M $MMM
R
GE ORAL LIABILITY EACOpOclultmIcs $1,000,000
A COMMERCIAL GENERAL LIABILITY CMWATORZN= 1300,000
CLAIMS-MADE OCCUR 8502AH221305 01/012015 01/01/2010 fxft nsuE ErmTw a)
r,+E;1 IP rArr ore 9017411 $5,000
Parlidosnts Lleb gV,Na $1,000,000
MRL A06RE0ATE LIMIT APPLIES PER: i ,E,EIA;gwT'�I'E nAr'E' $5,000,000
POLICY PRO- LOC CR'OO'ZT5.OgI,A AV's 52,000,000
JECT nj S
AUTOMOBILE LIABILITY QoKM =3;1%1=uhur(aW*1401t� S
ANY AUTO
I lIOMY=W1Rl'lwpRriRl S
ALL OWNED SCHEDULED I WMILYs>`ivwY OW w O&V S
AUTOS AUTOS I PRCOd1TY G! $
HIRED AUTOS NON-OWNED Oeree*
�. AUTOS S
X UMBRELLA LIAR I X OCCUR f;AC++OCCr:Rf15NCE S1,000,000
A EXCESS LIAR M cLxtiul- 4602AH221370 101/012015 01/012016 IAaGREWTe $i„ 00,000
^ 'A;E S
DED I $RETENTION'S
Ir10ORKERS COMPENSATION Y/N N/A IWC STATU-
AND EMPLOYERS'LIABILITY rro�L�MRa
ANY�ROPRrE�C�RCAR��ER�cU'T,y� S
OJTIcWME:Atn1E%CLu.. ? ELEIeG`aACC�^ R
(Mandatory in NH) I EL C4WASE-EFA EMKOYf:E $
Iryn.awftwserDESCRVTK)NO.F EL.D4E45E-POUCY041 S
4P�IIe1FT1O.VEr WfIGiM
00
Cats tro,
„A 0 01/01/2015 01/01/2016
r�ccleill phlc Acc„.. .II
.................f 4102AH305�2 � 01/012015 ' 01/012016 xMedical tcl:i°fUcUmi mt Limit 051000000 ,
DE'SCRIPTIOI1 OF OPERATI0II9 I LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,It more space Is required)
Coverage applies to teamsileagues comprised of 100%US Lacrosse members participants during scheduled and supervised Lwrosse activities.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
The City of El Segundo,its elected and appointed ofcials,ofBce s, ACCORDANCE WRH THE POLICY PROVISIONS,
agents and employees
350 Main St
El Segundo,CA 90245
AUTHORIZED REPRESENTATIVE k2i�r�
0 1888.2010 ACORO'CORPORATION. All rights reserved.
ACORD 26(201WOO) The ACORD r omet and toga arc regislered rnaralar of ACORD
POLICY NUMBER: 8502AH221369 COMMERCIAL GENERAL LIABILITY
U.S. Lacrosse Association
Policy Dates: 01/01/15-01/01/16 CO 20 11 01 96
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSONS OF
PREMISES
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE ;,
1. Designation of Premises(Part Leased to You): Athletic Facility
2, Name of Person or Organization(Additional Insured):
The City of EI Segundo,We elected and appointed
officials,officers,agents and employees
360 Main Street
EI Segundo,CA 90245 0000
Issued on behalf of:
LAYLL Events to take place April 14,2016-January 01,2016.
3. Additional Premium: NIL
(if no entry appears above,the information required to complete this endorsement will be shown in the Declara-
tions as applicable to this endorsement.)
WHO IS INSURED(Section II)Is amended to include as an Insured the person or organization shown in the
Schedule but only with respect to liability arising out of the ownership,maintenance or use of that part of the
premises leased to you and shown In the Schedule and subject to the following additional exclusions:
This insurance does not apply to:
1. Any"occurence"which takes place after you cease to be a tenant in that premises.
2. Structural alterations,new construction or demolition operations 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 Page 1 of 1
I certify that the team, league, or event on whose behalf I am
requesting this certificate mandates 100% membership in US
Lacrosse. In addition, I have verified our team's or league's events
roster and all participants are currently registered members of US
Lacrosse.
I certify that this is true and I understand that liability coverage is only
extended to our team, league, or event if all participants are current
members of US Lacrosse. Further, I acknowledge by clicking on this
box that event liability claims may be denied for coverage if our
team/league/event is not 100% registered with US Lacrosse.
Name: Brooks Roscoe
Organization: EI Segundo Lacrosse
Date: 04/24/2015
i
EI Segundo Lacrosse league
Workers Compensation Insurance Date: Feb 24,2015.
EI Segundo Lacrosse League is a not for profit club),and therefore not required to carry Workers
Compensation by the State of California.All our staff are volunteers.
j;
Signature
Business Automobile Insurance Date: Feb 24,2015
EI Segundo Lacrosse league is a not for profit club and we do not own or lease a Business Automobile.
Signature
Brooks Roscoe
Executive Director
EI Segundo Lacrosse Association &
EI Segundo Lacrosse League
EL SEGUNDO LACROSSE-AS CIATION
non-profit Oreanization
The goals of the EI Segundo Lacrosse Association (ESLA)are to promote the sport of lacrosse to
youth from Kindergarten through High School.
Our activities involve running games and tournaments in leagues year round on campus ES
fields and on the Rec Park roller rink. We also run camps and pay for expert coaches to run
occasional clinics.
We run a scholarship system based on need so that anyone who finds the cost of lacrosse too
high will not be denied a chance to play.
Our dues are collected and kept in an account by our treasurer. We add funds from operation
of the snack bar at Campus ES in the spring.
At no time in the past has our account exceeded$10,000.00. This will change with fee
collection and payment of player fees and rentals to the city, but our running balance should
return to under$10,000.00 each year.
Our volunteers include the directors listed below plus parents and high-school students acting
as coaches. Referees are paid professionals certified by national bodies.
We carry insurance in compliance with city regulations and we submit rosters and game
schedules to the city each season.
Contact for our group Is: ESLA care of Brooks Roscoe,409 E Oak Ave, EI Segundo, 90245.
Phone:310 227-5112 brooks.roscoe@gmail.com
Submitted by,
Brooks Roscoe Steven Wood Peter Bowen
Executive Director President Treasurer
Form Wmg Request for Taxpayer Give Form to the
(Rev.Daciarrkw 014) identification Number and Certiflcation requester.Do not
apeatntatt ar thsend to the IRS.
lntarnsi R Service
1 Name(as shown on your Income tax return),Non"Is required on Me line;do not leave this One blank.
EL SIAUMoo LAceossE / ssocl,trrjw
N 2 Business name/d'Isragarded entity name,If different from above
S Check appropriate box for federal tax claseffloation;check only one of the following seven tomes; 4 Exemptlons(codes,apply only to
❑Indlvlduabaole proprietor or ❑ C Corporation ❑S Corporation 09liarbwahip ❑Truwasiate' I cert ai
ctYions "per d)ividuals;a"
efngle-momber LIC Exempt payee code Of any)
j ❑U mIW Ila ity company.Enter the tax classllkzation(C=C corporation,SaS corporation,p-partnership)►
)S Note.For a single-member LLC that Is disregarded,do not check L.LC;check tiro appropriate box In the line above for Exemption ham FATCA reporting
the tax classification of the single-member owner. code Of arty)
0 Other(ase Instructions)► lMd.to•malb
8 Address(number.street,and spt or suit no,) Requestees name and adds (optional)
409 E oAV- k4i,
0 City,state,and?IBS code
.,,L 5i6urvool CA tqoq4S'
7 List account number(s)here(optional)
Taxpayer Idenutllrloetlon Number(TIN)
Falter your TIN In the approprlate box.The TIN provided must match the name given an line 1 to avoid II Social socurhy number
backup withholding.For individuals,this is generally your social security number(SSM.However,for a
resident ellen,sole proprietor,or disregarded entity,see the Part I Instructions on page 3.For other
entitles,It Is your employer Identiflcadon number MM.N you do not have a number,see Now to get a
TIN on page 3. or
Note.If the account is In more than one name,see the Instructions for line 1 and the chart on page 4 for Employer kJoiniffication number
guidelines on whose number to enter.OM
Cert i'Cation
Under penalties of perjury,I certify that:
1. The number shown on this form Is my correct taxpayer identification number(or I am waling 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 ORS)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.cldzon or other U.S.person(defined below);and
4.The FATCA code(s)entered on thlo form(if any)Indicating that I am exempt from FATCA reporting is correct.
CertiNcadon Instructions.You must cross Dort Item 2 above If you have been ratified 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,cancellatlon of debt,contributions to an individual retirement arrangement(IRA),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.
Here I uApawn: 'G� Dat.► Fe ISI
UIS—
General Instructions •Form 1091il Qrome mortgage Intassq,1091H (eiudent loan InteresQ,1098-T
(tuition)
Section references we to the Internal Revenue Code unless otherwise rated. •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such .Form 1089-A(acquisition or abandonment of secured property)
as leglslation enacted after we release It)Is at wwwJns.gov1Av9, Use Form W-9 only If you we a U.S.person pncluding a resident alley,to
Purpose of Form provide your coned TIN.
An individual or entity(Form W-9 requester)who is required to file an information K you do not return Form W-9 to the requassar with a 17N,you mlgnt be&AWd
return with the IRS must obtain you correct toxpaysr IdentlOatlon number MM to backup wfthholdBrg,See Whd Is baclwp''vwllhtnofd✓ig?on pegs 2.
which may be your social sooimify number(SM,lndlvlduel taxpoyer klentillcatlon By signing to filled-out form,you;
number QMP4.adoption taxpayer Idonlifloatk t number(ATiM,or employer 1.Gaudily that the TIN you we giving Is cored(orYou we waking for a number
Identification number(E'IM,to import on an Information returnthe amount paid to to be Issued),
You,or other amount reportable on an Information return.Examples of information 2.Certify that you aro not sub)ed to backup vAthlaldf or
Mums Include,but are not limited to,the folloy4ng: n9.
•Farm 10994NT Onte►est owned or polo 9.Claim exemption from backup withhold'I'ng If you sm a U.S,exempt payee,If
•Form 1099-DIV(dividends,Including than from stooks or mutual fiords) applloabl%you we also cortifying that as a U.S. n,your aifoo'oble share of
•Form 1099-MISC(various types of Income,pries,awards,or groes ) with�ibvg t Income from:
gr partners'•taws f a is not subject to the and
•Form 1099-8(stock or mutual fund who and certain other transections by 4.Certify that FATCA cods(a)entered on this foram Id an Indloating that you am
brokers) exempt from the FATCA reporting,is What Is i",49"t;„4 nepoWng?on
•Form 1099-5(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchurt card and third pasty network f wwscWm)
Cat No.10MIX Forth W-9(Rev.12-2014)