PROOF OF INSURANCE (2016) CLOSEDa [
ACC>Rl? CERTIFICATE OF LIABILITY INSURANCE DATE (MMMD/YYYY)
09/10/15
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: It the Certificate holder Is an ADDITIONAL INSURED, the pollay(les) must be endorsed. It 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 is), CO T
PRODUCER
Sterling Agency Insurance Services 800-991-2024
P.O. Box 12439
Marina Del Rey, CA 90295 INSURER 81 AFFnivnimp enyvp oE
NAIL INSURERA: Scottsdale Insurance ComDanv
INSURED
Serglu Boerica
DBA: Jaguar Tennis Academy
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.
R E OF INSURANCE A"b P
TYPE LIMITS
.TR 1114RM wun PQUSY NUMQ_FR IMM 0 Y1 i'MM on YYYI
51988 9/11/15 9111/16 1, EACH OCCURRENCE 000
X 100,000,
A X IT
� COMMERCIAL GENERAL LIABILY
CLAIMS MADE OCCUR X PS20 $
GENT AGGREGATE LIMIT APPLIES PER:
POLICY PO. LOC 7
JERCT
CT#4913�
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON-OWNED
HIRED AUTOS AUTOS
UMBRELLA LIAB OCCUR w.
EXCE88 LIAR CLAIMS-MADE
DEO Rg3LT1214 $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY 11'40PRIETORMARTNERMXECUTIVC� f -11 N I A
�rrk&CO�IAC�AMCM =vri i brictio
MED EXP (Any one
PRODUCTS -COMPIOP G $
VOROMP5
. . .. . ............
BODILY INJURY (Per person) 5
BODILY INJURY (Per accident) S
Y AMAGS
S
S
EACH OCCURRENCE 41
E.L. EACH ACCIDENT
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more specs Is required)
0
S
5,000
1000,000
1,666, 060
1,000.000
The City of El Segundo, its officers ' ',,,,Y SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
;y THE EXPIRATION DAA THEREOF, NOTICE WILL BE DELIVERED IN
officials,employees, agents, and officers, ACCCIAYNCE WITH THE POLICY PROVISIONS.
as Additional Insured 11 /
AUTHOR) ..# 4r TATNE
401 Sheldon Avenue
El Segundo, CA 90245
ttgO84014 ACORD CORPOR TiON, All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: CPS205198$ COMMERCIAL GENERAL LIABILITY '
CG 20 37 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETM OPERATIONS
This endorsement modifies insurance provided under the following:'
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured'Person(s) Location And Description Of Completed Opera -
Or Or° antzation s : tions
City of El Segundo, its officers, officials, employees, Recreation Park
agents and volunteers ,401 Sheldon St.
El Segundo, CA. 90245
Informatmon re aired to rom
to this Schedule if not hov a above will be shown in the Declarations.
Section II — Who Is An Insured is amended 18' include
as an additional insured the person(s) or organiza-
tion(s) shown in the Schedule, but only with respect to
k liability for "bodily injury" or "property damage" caused,
in whole or In part, by "your work" at the location desig-
nated and described in the schedule of this endorse-
ment performed for that additional insured and included
in the "products - completed operations hazard ".
CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 C3
Sergiu Boerica DBA Jaguar Tennis Academy
To whom it may concern,
I am a sole proprietor and not required to carry workers comp in the state of
California: therefore, I take responsibility for any injuries that I may incur while
providing a service to the City of El Segundo.
01
JI Ile
P( Sre
Signature
S ;- lu jC
Printed Name
22' A
Date
GEICO.
California Evidence of Liability Insuran
06100.00M Y!
1- 800 - 841 -9p00
wa �
GEICO GENERAL INSURANCE COMPANY�P
PO BOX 509090 SAN DIEGO,
CA 92160 9
NAIC Code: 35882
Policy Number
Effective D Expiration Date
4277475929
02 13 ` ' 08 -13 -16
Year Make
2000 FORD
I41ta� G.° Vehicle ID No.
1FMNU42F'OYEC87613
Insured:
� �,� w
VIRGINIJA KIRKILIENE
SERGIU BOERICA
906 E IMPERIAL AVE
APT 1
EL SEGUNDO, CA 90245 -2519