PROOF OF INSURANCE (2016) CLOSEDCERTIFICATE OF INSURANCE
1 01/2912016
PRODUCER
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO
American Specialty Insurance & Risk Services, Inc,
RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY
OR NEGATIVELY AMEND, EX TEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
7809 W. Jefferson Boulevard, Suite 100
BELOW. T1418 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT
Fort Wayne. Indiana 46804
BETWEEN THE ISSUING INSURER(81 AUTHORIZED REPRESENTATIVE OR PRODUCER AND
THE CERTIFICATE HOLDER.
INSURED
INSURERS AFFORDING COVERAGE
National Association of Sports Officials (NASO)
INS. A: Greenwich Insurance Company
2017 Lathrop Avenue
INS. B,
Racine, WI 53405
INS.. C:
JOHN ZIELLO
704 CAMINO REAL
REDONDO BEACH, CA 90277
CERT NUMBER: 1001280790
THIS I'S TO CERTIFY THAT 199 POLICIES OF INSURANCE UISTED BELOW HAVE BEEN ISSU
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIT}
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANOT
e
INS I POLICY POLICY POLICY
LTR TYPE POLICY NUMBER I EFFECTIVE I EXPIRAT'IO�
GL I ASGO89407201 1 08101/2015 1 08101/2016
A I I 12:01 a.m. 1 12:01 a.m.
XS I ASX089407401
A
08/01/2015 I 08/01/2016
12:01 a.m. 11 12:01 a.m.
THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING ANY
T TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY
INS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAR) CLAIMS.
Other Named Insured (conPd):but only while acting in their capacity as officials during sports event's organized by a recognized sanctioning body, such as local Park Department or any
formal organized association, and/or while attending seminars, conferences, and similar meetings designed to Improve, the'lr o#ficleting knowledge and Skills,
The Certlticate Holder shall be an Addltlonsl Insured, but only with respect to the operations of the Named Insured, and subject to the provisions and limitallons of Form CG 2010
Additional Insured - Owners, Lessees or Contractors - Scheduled Person or Organization, effective August 1, 2015
Other Named Insured:National Association of Sports Officlals(NASO) & NASO- member officials, including officials enrolled by associations, contracted with NASD,
- The general liability policy Is primary as per Form CG 00 01,
- Unintentional Errors & Omissions, $50,000 each wrongful acV$50,000 Annual Aggregate per officlelfasslgnor
CERTIFICATE HOLDER CANCELLATION
350 MAIN STREET
EL SEGUNDO, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES
SE CANCELLED BEFORE THE EXPIRATION DATE
THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
as A.S.I,R.SJ, Insurance Anen y in the stale of Callfdrnim
LiCY�Nt� � BEu 07��
COMMERCIAL GENERAL LIABILITY
CG 2010 0413
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Locations) Of Covered Operations
City of El Segundo, its officers, officials, employees,
Recreation Park
agents and volunteer's
401 Sheldon Street
but only with respect to John Mello ,.
El Segundo, CA 90245
4
Information required to comDlete this Schedule, if not shown above. will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to
B. With respect to the insurance afforded to these
include as an additional insured the person(s) or
additional insureds, the following additional
organization(s) shown in the Schedule, but only
exclusions apply:
with respect to liability for "bodily injury", "property
This insurance does not apply to "bodily injury" or
damage "personal personal and advertising injury
"property damage" occurring after:
caused, in whole or in part, by:
1. Your acts or omissions; or
1. All work, including materials, parts or
equipment fumished in connection with such
2. The acts or omissions of those acting on your
work, on the project (other than service,
behalf;
maintenance or repairs) to be performed by or
in the performance of your ongoing operations for
on behalf of the additiurral- insureds) at the
the additional insured(s) at the location(s)
location of the covered operations has been
designated above.
completed; or
However:
2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional
intended use by any person or organization
insured only applies to the extent permitted by
other than another contractor or subcontractor
law; and
engaged in performing operations for a
2. If coverage provided to the additional insured is
principal as a part of the same project.
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 2010 0413 0 ISO Properties, Inc., 2004 Page 1 of 2 13
ENDORSEMENT #06
This endorsement, effective 08/01/1512:01 a.m., forms a part of
Policy No. ASG089407201 issued to National Association of Sports Officials
by Greenwich Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
As of the effective date hereof, it is hereby understood and agreed that the attached Form CG 2010
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION Is added to the policy, but only with respect to John Ziello.
No additional premium due.
All other terms and conditions remain unchanged.
IXI 403 01 10 ® 2010 X.L. America, Inc. All Rights Reserved„
May not be copied without permission.
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase
applicable Limits of Insurance shown in
Declarations.
of
the
the
CG 2010 0413 0 ISO Properties, Inc., 2004 Page 2 of 2 O
EVIDENCE OF INSURANCE COVERAGE
Insurance identification cards are provided below. Please retain one card in the referenced vehicle. An
additional card is available as required by some states for vehicle registration. CSE provides insurance
information electronically to the CA, AZ and NV Department of Motor Vehicles.
`" Insurance Group
_ ___V" N . ,
Insured Name and Address
ZIELLO, MARY P
704 CAMINO REAL
REDONDO BEACH, CA 90277
Policy Number. CAAB002278
Effective Date: 11/11/2015
Expiration Date: 05111/2016
California Proof of Automobile
Liability Insurance
NAIC 10693
Agent:
BICHLMEIER INSURANCE SRVS INC
caryb@bieine.com
Address
730 S PACIFIC COAST HWY #201
REDONDO BEACH, CA 90277
Ph. 800 - 888.7187 Fx 310 - 540.2215
2013 FORD C -MAX ENERGI PLUG -IN 1FADP5CU3DL539943
CSE Insurance Group
wia 190
Insured Name and Address
ZIELLO, MARY P
704 CAMINO REAL
REDONDO BEACH, CA 90277
Policy Number: CAA8002278
Effective Date: 1 1 /1 112 01 5
Expiration Date: 05/11/2016
California Proof of Automobile
Liability Insurance
NAIC 10693
Agent,
BICHLMEIER INSURANCE SRVS INC
caryb (abislns.com
Address
730 S PACIFIC COAST HWY 9201
REDONDO BEACH, CA 90277
Ph. 80.888.7187 Fx 310.540 -2215
2012 FORD TRANSIT CONNECT XLT NMOKSOCN9CT113461
CSE Insurance Group
California Proof of Automobile
t919
Liability Insurance
NAIC 10683
Insured Name and Address
Agent:
ZIELLO, MARY P
BICHLMEIER INSURANCE SRVS INC
earyb ®bisins.com
704 CAMINO REAL
REDONDO BEACH, CA 90277
Address
730 S PACIFIC COAST HWY #201
REDONDO BEACH, CA 90277
Policy Number: CAA8002278
Effective Date: 11/11/2015
Expiration Data: 05111/2018
Ph. 800. 888 -7187 1`010.540 -2215
2013 FORD C -MAX ENERGI PLUG -IN 1FADP5CU3DL639943
w CSE Insurance Group
wxr 1549
Insured Name and Address
ZIELLO, MARY P
704 CAMINO REAL
REDONDO BEACH, CA 90277
Policy Number: CAA8002278
Effective Date: 11/11/2015
Expiration Date: 05/11/2016
California Proof of Automobile
Liability Insurance
NAIC 10693
Agent:
BICHLMEIER INSURANCE SRVS INC
earybQbislns.com
Address
730 S PACIFIC COAST HWY 9201
REDONDO BEACH, CA 90277
Ph. 80o- 888.7187 Fx310.540.2215
2012 FORD TRANSIT CONNECT XLT NM0KS9CN9CT113461
lks)
A to Z Officiating
A to Z Officiating: does not need or carry workers compensation insurance as we
are independent contractor therefore, I take responsibility for any injuries that I
may incur while providing a service to the City of El Segundo.
Date