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PROOF OF INSURANCE (2017) CLOSEDUKINT -2 OP ID. WK A+I f RO DATE IMWODNYM CERTIFICATE OF LIABILITY INSURANCE F04108/2016 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(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 Ileu of such endomemont(s).. PRODUCLR RPS Bolli or Sports 3 Leisure PO Box 32 Short Hills, NJ 07078 -5000 John T. Splotta INSURaD Inc PO Box 1838 Redlands, CA 82373 •MUkel POLICY NUMBER: 8502AH238111 - 14 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 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 PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of E1 Segundo 350 Main St. E1 Segundo, CA 90248 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph B. Transfer Of Rights Of Recovery Against Others To Us of Sec- tion IV- Conditions: 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 ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 1 Policy Change Number 5 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERED BELOW: SSE IL 12 01 11 85 Copyright, ISO Commercial Risk Services, Inc., 1983 04 -07 -2016 POLICYHOLDER COPY Sd P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04 -01 -2018 CITY OF EL SEGUNDO Sd DEPT OF BUILDING & SAFETY 300 E PINE AVE EL SEGUNDO CA 80245 -3088 GROUP: POLICY NUMBER: 1880817 -2018 CERTIFICATE 10: 13 CERTIFICATE EXPIRES: 04 -01 -2017 04- 01- 2018/04 -01 -2017 This is to certify that we have issued a valid Workers' Compensation insurance policy In a form approved by the California Insurance Commissioner to the employer named below for the policy period Indicated. This policy Is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to Its normal expiration. This certificate of Insurance is not an Insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be Issued or to which It may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. (/lii.�ll�I� �1(/Mrl1i Authorized Representatxwa President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015 -04 -14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #1800 - ALSOP, NICK, VP,SEC - EXCLUDED. ENDORSEMENT #1800 - GAMBLE, GARY, PRES,TRES - EXCLUDED. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018 -04 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER UK INTERNATIONAL SOCCER CAMPS INC Sd PO BOX 1838 REDLANDS CA 92373 IP1 M,S.n IREV.7 -20141 PRINTED : 04 -05-2018 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: rr � w � � � � � w �w � r r +� . r • � +r 2. To apply the % surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5,000.00 Sample Rate: 13.30% Regular Premium equals: $ 665.00 Surcharge: 3.00 Additional Waiver charge: $ 19.95 Total premium equals $ 684.95 (665.00 + 19.95) ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 1890817 -16 RENEWAL SJ 4- 24 -57 -59 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE APRIL 1, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 1, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME UK INTERNATIONAL SOCCER CAMPS INC PO BOX 1838 REDLANDS, CA 92373 r� ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, UK INTERNATIONAL SOCCER CAMPS 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: APRIL 6, 2016 ALxTHOR17EE] REPRE aENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7 -2014) 2570 OLD DP 217