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PROOF OF INSURANCE (2016 - 2016) CLOSED0425 ^� DATE (MMlDDlY'rYYi CERTIFICATE OF LIABILITY INSURANCE 1111612015 DDIY 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 _ /alf, Pi 7..,. Fgl- .,,..µ��.._. -�B, C Wil is Insurance Services of Georgia, Inc, One Glenlake, Suite 1100 PHONE rAla Atlanta, GA 3032$ w -'- E nA9L NNSURERI�) AFFOR12!tL www.viillis.com INSURER A: Everest National Insuranc _,...�.�... _r „,�._.. „,,._.- .. �,...__.....„......_....__..... �._,,., m_.„.._.... .,._..„.„._..�„.._ „....„..,.._. m...„.... _...... INSURER B _ INSURED California State Soccer Association — South Cal South Youth) INSURER C: 1029 South Placentia Avenue INSU_R_ER 0: _ _ Fullerton CA 92831 INSURER „ E._.___....._._..._.... ....___._...._..�..�..__.._�.�_ COVERAGES CERTIFICATE NUMBER: 27317094 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. POiDYr �a. ' „NS ,. - _ .......___..._.. I �n Y LIMITS _ TR TYPE OF INSURANCE pOLiCYNUMB£R MMMfY` MMIDDrrYy _ A ,” COMMERCIAL GENERAL LIABILITY �/ �/ S18ML00379 -151 91112015 9111201$ EACH OCCURRENCE 5 1,000,000 CLAIMS -MADE D OCCUR PRg bw 1,000,000 Participant _ e g al L.a..b_ lli .T... M_ D _E._XP An_.s..._... _ . y _p _M. 5,000- AUSe & OleStatlOn PERSONAL 8 ADV INJURY S 1.000,000 W ENL AGGREGATC LIMIT APPLIES PER: 3,000,000 _ PraLIC "f' PRO- +" JECT Lcc PRODUCTS - COMPIOPAGO S 3000,000 OTr1;ER: Team '2aM A e Abuse & Molestation $ Included _ _ AUTOMOBILE LIA131LITY ^� . .)MBINIED SINGLE LIMIT ANY AUTO I person) ' BODILY INJURY Per erson S m,,,. ALL OWNED SCHEDULED BODILY INJURY (Per accident S AUTOS AUTOS I _ NON -OWNED iFTtP�YCIliai, _.. _ HIRED AUTOS AUTOS r 7[rr acc xti I S UMBRE A UMBRELLA LIAR OCCUR Si8tr7000309 -151 9/1/2015 9/112016 EACH OCCURRENCE 2.000 DOD'. _s LIAR 'CLAIMS -MADE AGGREGATE S _.._,. 2,00fl 000 OEn RETENTIONS COMPENSATION EMPLOYERS' E AND LIABILITY YIN RH i ANYPROPRIETORIPARTNERIEXECUTIVE .NIA E,L EACH_A_C_CIDENT S OFFIDERdMEMBER EXCLUDED?.._ _ _ (Mandatory In NNI E,L DISEASE - EA EMPLOYEE'S 11 wiler ... .,...__ ._.._...,_ ......__....._....... ..„„ ...... _ - --. .....,., OESC:r1IPTI0NOF OPERATIONS bereow E..L DISEASE - POLICY LIMIT 5 DESCRIPTION OF OPERATIONS 1 LOCATIONS r VEHICLES (ACORD 101, Addlrional Remarks Schedule, may be attached N more space is requlred) LEAGUE: 0425 LEAGUE NAME: South Bay Force FC ADDRESS: PO Box 7000 -879 Redondo Beach CA 90277 -8710 *Med Pay applies for spectators only. Certificate Holder is an additional insured as respects CalSouth youth soccer sanctioned events only where required by written contract and per attached endorsement. The City of El Segundo, its officials, employes are named as additionally insured with respect to General Liability. General liability is primary. Waivers of subrogation applies to the workers Compensation in favor or the city of Et Segundo CERTIFICATE HOL'D'ER CANCELLATION City Of l Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y 9 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: L Se Undo' recreation and Parks �`; ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Sp, 'eet El Segundo CA 90245 l AUTHORIZED REPRESENTATIVE Ter Michelitch ©1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 27317094 1 2015 -2016 League Liability I Tim Surrmiel 1 11/16/2015 1:32:37 PM (EST) I Page 1 of 1 This certificate cancels and supersedes ALL previously issued certificates. S18ML00379 -151 California State Soccer Association — South (Cal South Youth) 11/23/2015 COMMERCIAL GENERAL LIABILITY ECG 24 522 04 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. City of El Segundo Attn: EL Se undo Recreation and Parks 350 Main Sreet El Segundo CA 90245 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your operations or "your work" done under a written agreement that requires you to waive your rights of recovery. The written agreement must be made prior to the date of the "occurrence ". This waiver applies only to the person or organization shown in the Schedule above. ECG 24 522 04 02 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 27409714 1 2015 -2016 League Liability I Tim Summiel 1 11123/2015 4:26:52 PM (SST} 1 Page 2 of 2 Thin certificate cancels and sunersedos ALL previously iosued certiiic3Les. Page 1 of 1 ❑ SOUTH -6 OP ID: LM CERTIFICATE OF LIABILITY INSURANCE DATE 7/0 12015 07!01!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 Robert !telly Dodge Insurance Services Inc, DBA". Arroyo In- Laurance Services _ r nx 825 LAIC No E�EI 370 356 B206 rnrrw Ne 310-316-1825 ^ 3610 Torrance Blvd., Suite 305 HOTEL mm _ . Ae�,Rysrobertk atria coca coITM mmIT Torrance, CA 90503 Robert J. Kelly fN5llrtER(S) AFFORDING COVERAGE NAIL LTR TYPE OF INSURANCE POLICY NUMBER INSURER A : State Compensation Ins Fund 35076 South l3a FO d13a: ._.- .m.___. _.....__._..... .�...,,.- ..�.,._.,.,,W...µ...,. .......-. .,.,._._.._,,,....�.�.,_...._.� - �,. m.,-,.-..... ...... ........... ..�...,.-- ...w_ -..W4 _,.._. INSURER 8: L A Galaxy South Bay P O Box 7000.879 lNSVRERC: Redondo Beach, CA 90277 INSURER D: INSURER F: COVERAGE'S 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. fNSR .....r . ucn in. � CtV S P LTR TYPE OF INSURANCE POLICY NUMBER fMM1OQ1VYV1 MMrCDIYYkY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR � _MED E_XP (Any one person) $ µ_...-.-. ..a..- ...,...- ...__....�.....- . ..PER "AL 8 ADV INJURY,.$... GE, N'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S PRO- 11 ❑ �— POLICY JECT LOC PRODUCTS COMP /OP AGG S ..... .... ... AUTOMOBILE LIABILITY MINNC f ifl L1MI S. i��e rsa.cadrznM� ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILYINJURY(Peraccidentl S .. NON -OWNED '.... PRi PFR7 P OAMA , £ $ - -_,.. HIRED AUTOS AUTOS lPcr, aIMrnr .. S UMBRELLA LU1B fCLAIIMS-MADE CCR EACH OCCURRENCE _ $ '.. ....AGGREGATEW .. EXCESS LIAB...Y_ $ _ y.Y ... ..W., DEO RETENTION ELATION S $ 'Yw°08i'JKE,R$ COMPENSATION X STATUTE R H EMPLOYERS' LIABILITY AND E Y A ANY PROPRIETORT 'ANrNERI- 6XECUTIV'E X 990341015 071 0112015 0710112016 E.L. EACH ACCIDENT 5 1,000,00 orRlc EAAAEM8r;R EXCLUDED? El NJA (Mandatory In NN) E.L. DISEASE - EA EMPLOYEE S 1,400,00 i li es, dase.nt umdrrr D_ CRIRIP'NON FF O ERATIONS beMa .L DISEASE - POLICY LIMIT $ 1,000,40 I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additlonal Remarks Schoduler may be attached if more space is required) Waiver of Subrogation in favor of the City of El Segundo, as per attached. CERTIFICATE HOLDER CANCELLATION CTES005 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN iCity of El Segundo ty g ACCORDANCE WITH THE POLICY PROVISIONS. Recreation & Parks Department 401 Sheldon Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE �. ©1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION EFFECTIVE JULY 1, 2015 AT 12.01 A.M. AND EXPIRING JULY 1, 2016 AT 12.01 A.M. SOUTH BAY FORCE JOHN MOODY PO BOX 7000 -879 REDONDO BEACH, FC INC CA 90277 REP 05 1903410 -15 RENEWAL SC 5- 53 -52 -70 PAGE I OF 1 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGAT'I'ON 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: JULY 1, 2015 AlJ "I')kC�I�)Eb'� I�FFIIrSI:N"i 1VF' SCIF FORM 10217 IREV_7 -2014) PRESIDENT AND CEO 2570 OLD DP 217