PROOF OF INSURANCE (2016) CLOSED4coo V�
CERTIFICATE OF LIABILITY INSURANCE
ERTIFICATE 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 teams 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),
PkODUCER CONTACT
NAB: Frazier Insurance Agency, Inc.
Frazier Insurance Agency, Inc.
P.O Box 1250
Midlothian, VA 23113 -1250
INSURED
Sports a Recreation Pmvldors Assn. Risk Management, Inc.
El Segundo Inline Hockey Association
PO Box 3061
El Segundo, CA 90245
(AVC No, Ft): (804) 754 -7610 (804) 754 -7613
E�MAil.
ADD1tEss: ifrazler @frazlennstirar)ce.com
INSURER(S) AFFORDING COVERAGE NAIL t
INSURERA. United States Fire Insurance Company 21113
INSURER B:
INSURERCs
INSURERD,
INSURERE:
INSURER F:
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
iYPEOFDwsuRANCE OF SUCH NSR POLICIES. LIMITS SHOWN
LIMAY HAVE BEEN REDUCED
MI CLAIMS.
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T GENER LIABILITY
MWRCIALGENERALL.IAZUTY
CLAIIAS4AADE L - • I OCCUR
INCLUDES ATHLETIC PARTICIPANTS
GENL AGGREGATE LAWT APPUEe PER
X POLICY LIM
AUTOMOBILE LIABILITY
ANYAUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HMEDAUTO NON-OWNED
AUTOS
UMBRELLALIAB OCCUR
EXCESS LIAR CLAVASMADE
DED.. I I RETENTION 3
GENERAL AGGREGATE $ Z
PRDDUCTS- COMPIOPAGG $ 2
PERSONAL & ADV INJURY S )
SRPGP- 101 -0715 10115/2015 10/15/2016 EACHOCCURRENCE $
1
12.01 AM FIRE DAMAGE (Any .fre) $
MED EXP (Any one person) $
$
DESCRIPTION OF OPERATIONS/ LOCATIONS I V EHICLES (Attach ACORD 101. Additional Remarks Schedule, if more space is required)
POLICY DEDUCTIBLE: $0.00 PER EACH BODILY IN.MJRY OR PROPERTY DAMAGE CLAIM.
CERTIFICATE HOLDER CANCELLATION
El Segundo I nline Hockey Association
PO Box 3061
El Segundo, CA 90245
ACORD 25 (2010105)
$
S
S
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
lofmW Tlu if r
®1988 -2010 ACORD CORPORATION. All rights reserved.
Tho Ar:r)Pr1 n*nna onr( lnnn w= ronieforaA nnarlrc evf Ar.OPr1
CO IERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Insured: El Segundo Inline Hockey Association, Inc.
Policy Number. SRPGP -101 -0414
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organizatign(s)
The City of El Segundo
350 Main St
El Segundo, CA 90245
Information required to complete this Schedule, if not shown above will be shown in the Declarations.
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 ® ISO Properties, Inc., 2004 Page 1 of 1 13
`
Section II - WHO IS AN INSURED is amended to
include as an insured the person(s) or organization(s)
shown in the Schedule, but only with respect to liability
for "bodily injury", "property damage* or 'personal and
advertising injury" caused, in whole or in part, by your
acts or omissions of the acts or omissions of those
acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 ® ISO Properties, Inc., 2004 Page 1 of 1 13
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Workers Compensation Insurance
Date: 3 1 t s
A i' (Agency's name) is a (type of organization), and therefore not required to
carry Workers Compensation by the State of California. ��f 4A— (Agency's name) staff are
me rs
Signature
Business Automobile Insurance
Date: '� - 6t5
Signature
uy
(type of organization) do not own or lease a Business
ass
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e
IRA C e`aerlmenl of the Trw°a�asrzl ,
=at Revenue Service
P.O. Box 2508
Cincinnati OH 45201
EL SEGUNDO IN -LINE HOCKEY
ASSOCIATION INC
EDWARD CZERWINSKI
PO BOX 3061
EL SEGUNDO CA 90245 -8161
In reply refer to: 0248653327
May 06, 2010 LTR 4168C EO
95- 4543940 000000 00
00019553 �
BODC: TE
029670
Employer Identification Number: 95- 4543940
Person to Contact: Ms. Espelage
Toll Free Telephone Number: 1- 877 - 829 -5500
Dear Taxpayer:
This is in response to your Apr. 27, 2010, request for information
regarding your tax - exempt status.
Our records indicate that your organization was recognized as exempt
under section 501(c)(3) of the Internal Revenue Code in a
determination letter issued in August 1996.
Our records also indicate that you are not a private foundation within
the meaning of section 509(a) of the Code because you are described in
section(s) 509(x)(1) and 170(b)(1)(A)(vi).
Donors may deduct contributions to you as provided in section 170 of
the Code. Bequests, legacies, devises, transfers, or gifts to you or
for your use are deductible for Federal estate and gift tax purposes
if they meet the applicable provisions of sections 2055, 2106, and
2522 of the Code.
Beginning with the organization's sixth taxable year and all
succeeding Years, it must meet one of the public support tests under
section 170(b)(1)(A)(vi) or section 509(x)(2) as reported on Schedule
A of the Form 990. If your organization does not meet the public
support test for two consecutive years, it is required to file Form
990 -PF, Return of Private Foundation, for the second tax year that the
organization failed to meet the support test and will be reclassified
as a private foundation.
If you have any questions, please call us at the telephone number
shown in the heading of this letter.
Form `_ rte,
(Rev. December 2014)
Department of the Treasury
Internal Revenue Service
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Request for Taxpayer Give Form to the
Identification Number and Certification requester. Do not
send to the IRS.
1 Name (as shown on your income tax return). Name is required on
El Segundo In -Line Hockey Association Inc.
2 Business name /disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to
El Individual /sole proprietor or ❑� C Corporation El S Corporation El Partnership E] Trust/estate certain entitles, not individuals; see
instructions on page 3):
single - member LLC
❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) 10. Exempt payee code (if any)
Note. For a single- member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for Exemption from FATCA reporting
r—y the tax classification of the single - member owner, code (if any)
I 1 Other flee In'str ctionsl ► I (ap to acc Ms �Wwned o Iwde ft U.S.)
or
PO Box 3061
6 City, state, and ZIP code
El Segundo, CA 90245
7 List account number(s) here (optional)
name
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number �(
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 is your employer identification number (EIN). If you do not have a number, see How 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 jdentiftoation number
guidelines on whose number to enter.
9 5 1 4 1 5 1 4 1 3 1 9 4 1 0
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 form (f any) indicating that I am exempt from FATCA reporting is correct.
Certification 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 aj,pdonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments othe i";n in ere t an4 dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
Here U.S. person ► Date ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W -9 (such
as legislation enacted after we release it) is at ww vJrs.gov /fw9.
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 security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification 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 -INT (interest 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 -K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098 -T
(tuition)
• 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.
If you do not return Form W -9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (If any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cat. No. 10231X Form W -9 (Rev. 12 -2014)