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PROOF OF INSURANCE (2017) CLOSED
�� 0 I DATE(MMIDD/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 12/12/2016 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(ies)must have ADDITIONAL INSURED provisions or 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). CONTACT PRODUCER NAME; American Specialty Insurance&Risk Services,Inc. PH E Ext! 260-969-5203 jnr No,) 260-969-4729 dba A.S.I.R.S.I.Insurance Agency ADDSS: 7609 W.Jefferson Blvd.,Suite 100 INSURERS)AFFORDING COVERAGE NAIC# Fort Wayne IN 46804 INSURERA: Greenwich Insurance Company 22322 INSURED INSURER B: National Association of Sports Officials(NASO) INSURER C: 2017 Lathrop Avenue INSURER D: INSURER E: Racine WI 53405 INSURER F: COVERAGES CERTIFICATE NUMBER: 1001368349 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 3OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS I� .,,...` ' ADDLLSUgR POLICY EF'F I1 POLICY EXP LIMITS OF INSURANCE INSD WVD POLICY NUMBER (AMIDwYYYYI IMMODFYYYY'p X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO Rf-.Nff-'0 CLAIMS-MADE X I OCCUR PRFMISL'S $ 1,000,000 MED EXP(Anv one person) $ Excluded A N ASGO89407202 08/01/2016 08/01/2017 PERSONAL&ADV INJURY $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES GENERAL AGGREGATE $ 5,000,000 POLICY PRO JE O. D LOG PRODUCTS-COMP/OP AGG $ 5,000,000 X ,ji.iCR OFFICIAL $ n AUTOMOBILE LIABILITY (rgMty O rtl)SINGLE LIMIT $ �I ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accidenl) AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY E AUTOS ONLY AUTOS ONLY Per accident} DAMAGE IUMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A XN EXCESS LIAB CLAIMS-MADE N N ASX089407402 08/01/2016 08/01/2017 AGGREGATE $ 2,000,000 9d DED ( RETENTION$ PROD-COMP OPS AGG $ 2,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN I STATUTE I IF..R ANYPROPRIETORIPARTNER/EXECUTIVE I----1 E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? u N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEEI $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Unintentional Errors&Omissions,$50,000 each wrongful acV$50,000 Annual Aggregate per official/assignor Other Named Insured:National Association of Sports Officials(NASD)&NASO-member officials,including officials enrolled by associations,contracted with NASD, CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO, ITS OFFICERS,ELECTED AND APPOINTED OFFICIALS,EMPLOYEES AND MEMBERS OF BOARDS,COMMISSIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE AND VOLUNTEERS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET AUTHORIZED REPRESENTATIVE i EL SEGUND0 CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: �u ACC?R " ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED American Specialty Insurance&Risk Services,Inc. National Association of Sports Officials(NASD) POLICY NUMBER 2017 Lathro p Avenue ASG089407202 CARRIER N DE Racine WI Greenwich Insurance Company.............r....................... ..22322 V EFFECT 'EDATE3.4„ .5......,,,,........08/01./2.0.1.6.............. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 2a FORM TITLE: CERTIFICXrE OF LIABILI°I°Y INSURANCE-Certificate#1001368349 ..... ...................................................................................................................................................... Other Named Insured(cont'd):but only while acting in their capacity as officials during sports events organized by a recognized sanctioning body or organized by another entity,but the rules of a recognized sanctioning body are followed,such as local Park Department or any formal organized association, and/or while attending seminars,conferences,and similar meetings designed to improve their officiating knowledge and skills. Coverage applies to JOHN ZIELLO,704 CAMINO REAL,REDONDO BEACH,CA 90277. The general liability policy is primary as per Form CG 00 01. The Certificate Holder shall be an Additional Insured,but only with respect to the operations of the Named Insured,and subject to the provisions and limitations of Form CG 2010 Additional Insured-Owners,Lessees or Contractors-Scheduled Person or Organization,effective December 12,2016 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER:ASG089407202 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 ADDITIONAL INSURED - OWNERS, LESSENS OR CONTRACTORS - SCHEDULED ED 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) Location(s)Of Covered Operations CITY OF EL SEGUNDO, ITS OFFICERS, ELECTED AND APPOINTED OFFICIALS, EMPLOYEES AND MEMBERS OF BOARDS, COMMISSIONS and VOLUNTEERS 350 Main Street El Segundo, CA 90245 but only with respect to John Ziello Information required to complete 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" or "personal and advertising injury "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished 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 additional insured(s) 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 20 10 0413 © ISO Properties, Inc., 2004 Page 1 of 2 ❑ C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 0413 0 ISO Properties, Inc., 2004 Page 2 of 2 ❑ ENDORSEMENT#09 This endorsement, effective 12/12/16 12:01 a.m., forms a part of Policy No.ASG089407202 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. Insured Copy CSERenewal Personal Auto Policy INSURANCE GROUP Civil Service Employees Insurance Company P.O.Box 8041,Walnut Creek,CA 94596-8041 To continue coverage, please send In your payment by 11/1112016.Thank you PHONE.800-282-6848 * www.cselnsurance.coin for Insuring with CSE. Policy# Policy Term(begins and ends at 12:01a.m.Standard Time) Notice Date CAA8002278 From 11/11/2016 to 05/11/2017 000 10/06/2016 Named Insured and Address Agent BICi l-METER INSURANCE SRVS INC c,aryb@bisins.com ZIELLO, MARY P 704 CAMINO REAL Address Code 41644-41644 REDONDO BEACH,CA 90277-4317 730 S. PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 Phone 800-888-7187 Fax 310-540-2215 Vehicles are covered pursuant to the terms and conditions of the contract Terr/ Annual Stated Deductible Veh ST RBG Year Make/Description Serial Number Use Mileage Symbol Amount OTC Col Class 004 CA 999 12 FORD TRANSIT C NMOKS9CN9CT11346 B 12,000 21/23 N/A 500 500' 840100 005 CA 999 16 FORD EDGE SEL 2FMPK3J91GBB60321 P 10,500 30/23 N/A 500 500' 88D100 Insurance is provided where a premium is shown for the coverage Coverage Limits of Liability Premiums Ea Person Ea Occurrence Veh.004 Veh.005 FORD FORD Bodily Injury $ 25,000 $ 50,000 $ 61.50 $ 49.90 Property Damage $ 25,000 $ 58.10 $ 47.40 Uninsured Motorist BI $ 25,000 $ 50,000 $ 12.50 $ 10.20 Underinsured Motorist BI Limits included in Uninsured Motorist BI Limits above $ 5.20 $ 4.20 Other than Collision-See deductible limit above $ 36.00 $ 45.10 - Collision-See deductible limit above $ 183.90 $ 182.00 *Uninsured Motorist-Waiver of collision deductible $ 9.40 $ 9.40 Roadside Assistance Up to 100 miles towing $ 5.00 5.00 Roadside Assistance Up to 100 miles towing $ _ Optional Transportation Expenses Limit $ 35/per day $ 910/max $ 10.00 $ 10.00 Fraud Assessment Fee $ 0.50 $ 0.50 Fraud Interdiction Fee $ 0.25 $ 0.25 Insurance Consumer Services Fee $ 0.13 $ 0.13 Total By Vehicle $ 382.48 $ 364.08 Good Driver Discount Applied Total Policy Premium $ 746.56 *Uninsured Motorist-Waiver of collision deductible applies to those vehicles that have a premium shown. Insured Billed Continued on next page Policy# CAA8002278 Agent BICHLMEIER INSURANCE SRVS INC From 11/11/2016 To 05/11/2017 E-mail id 4164441644 Phone 800-888-7187 Insured ZIELLO,MARY P Discounts Day Good Good Driver Multi- Multi- Anti- Time Senior Persis- Vehicle Driven Student Training Car Policy Theft Airbag Lights Driver tency 004 Y N N Y Y Y N' Y N Y 005 Y N N Y Y Y N' Y N Y 'Airbag discount does not apply because policy does not include Medical Payments coverage. Surcharge Performance Coverage Vehicle Accident Citation Vehicle Lapse 004 N N N N 005 N N N N Driver Information Years Marital ID Status Driver Name License Number Licensed Birth Date Status Sex 001 PRIMARY ZIELLO, MARY P. On File 45 03/23/1955 M F 002 PRIMARY ZIELLO,JOHN E. On File 44 04/06/1956 M M Policy includes the following forms and endorsements Form Number Vehicle Description F.30905B 05/07 ALL Part D-Coverage for Damage to Your Auto F.31485A 05/01 ALL Privacy Notification F.31880B 08106 ALL Amendment of Part D Coverage F,32640A 08/06 ALL Equivalent Replacement Cost F.32650A 08106 ALL CSEICO Amendatory Endorsement F.32845A 01/07 ALL Contact Information Notice F.33805C 08/12 ALL Policy Discounts PPA0303 06/16 005 Roadside Assistance PPA0303 06/16 004 Roadside Assistance PPA0305 08/86 004 Loss Payable Clause PPA0319 08/86 004 Additional Insured Lessor PP0001 01/05 ALL Policy Contract PP0169 08/05 ALL Waiver of Collision Deductible PP0321 01105 ALL Limited Mexico Coverage PP0487 08/05 ALL UM-CA PPA0302 06/98 004 Optional Limits Transportation Expenses Coverage PPA0302 06198 005 Optional Limits Transportation Expenses Coverage Additional Interests Vehicle Loss Payee-001 004 SOUTH BAY CREDIT UNION PO BOX 4610 SIOUX CITY, IA 511044610 Garage Location(if other than named insured's address) Vehicle Location Address Vehicle Location Address 004 704 CAMINO REAL 005 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 REDONDO BEACH,CA 90277-4317 Program Civil Servant CODE DESCRIPTIONS VEHICLE DESCRIPTION VEH -INDICATES NUMBER OF VEHICLE. ST -STATE WHERE THE VEHICLE IS GARAGED. TERR/RBG -RATING BAND GROUP WHERE VEHICLE IS GARAGED. YEAR -MODEL YEAR OF THE VEHICLE. USE -USE OF VEHICLE:P=PLEASURE,B=BUSINESS,F=FARM,W=DRIVE TO WORK, OR IF CA CIVIL SERVICE EMPLOYEES INSURANCE COMPANY: W1=DRIVE TO WORK LESS THAN 126 MILES WEEKLY W2=ALL OTHER WORK USE SYMBOL -"SYMBOL"IS USED TO CLASSIFY VEHICLES OF THE SAME TYPE FOR PRICING THE INSURANCE COVERAGE ON THE VEHICLE.COST NEW MAY APPEAR IN PLACE OF THE SYMBOL FOR MOTORHOMES AND SELECTED PICKUPS AND VANS. STATED AMOUNT -THIS IS THE VALUE USED TO SET FORTH THE LIMITS OF THE OTHER THAN COLLISION AND COLLISION COVERAGES FOR TRAILERS,SPECIAL AND CLASSICAL VEHICLES. DEDUCTIBLE OTC -INDICATES THE OTHER THAN COLLISION COVERAGE DEDUCTIBLE FOR THIS VEHICLE, DEDUCTIBLE COLL -INDICATES THE COLLISION COVERAGE DEDUCTIBLE FOR THIS VEHICLE, DISCOUNTSISURCHARGES INDIVIDUAL DISCOUNTS APPEAR ONLY FOR THE STATES WHERE DISCOUNT IS OFFERED. A"Y'UNDER THE INDIVIDUAL CATEGORY INDICATES THAT THIS DISCOUNT OR SURCHARGE HAS BEEN APPLIED TO THIS VEHICLE. RATING INFORMATION CLASS CODE - 6-DIGIT CLASSIFICATION CODE WHICH REFLECTS CERTAIN ELEMENTS USED IN DETERMINING THE PREMIUM FOR THE VEHICLE. 1ST DIGIT- "8"FOR PRIVATE PASSENGER 2ND DIGIT- REFLECTS THE GENDER,MARITAL STATUS,PRINCIPAUOCCASIONAL OPERATOR STATUS OF THEVEHICLE'S RATED DRIVER. 1"INDICATES FEMALE,SINGLE,OCCASIONAL OPERATOR. "2"INDICATES FEMALE,SINGLE,PRINCIPAL OPERATOR, "3"INDICATES FEMALE,MARRIED,OCCASIONAL OPERATOR. "4"INDICATES FEMALE,MARRIED,PRINCIPAL OPERATOR. "5"INDICATES MALE,SINGLE, OCCASIONAL OPERATOR. "6"INDICATES MALE,SINGLE, PRINCIPAL OPERATOR. "7"INDICATES MALE,MARRIED,OCCASIONAL OPERATOR. "8"INDICATES MALE,MARRIED,PRINCIPAL OPERATOR. "X"REFLECTS EXTRA VEHICLE. 3RD DIGIT- REFLECTS THE NUMBER OF YEARS LICENSED. "0-9"REFLECTS THE NUMBER OF YEARS LICENSED. "A"REFLECTS THE NUMBER OF YEARS LICENSED 10-15. "B"REFLECTS THE NUMBER OF YEARS LICENSED 16-23. "C"REFLECTS THE NUMBER OF YEARS LICENSED 24-38. "D"REFLECTS THE NUMBER OF YEARS LICENSED 39-54. "E"REFLECTS THE NUMBER OF YEARS LICENSED 55-60. "F"REFLECTS THE NUMBER OF YEARS LICENSED 61+. "X"REFLECTS EXTRA VEHICLE. 4TH DIGIT- "1"INDICATES NEITHER DRIVER TRAINING NOR GOOD STUDENT APPLIES. "2"INDICATES GOOD STUDENT APPLIES,BUT DRIVER TRAINING DOES NOT APPLY. "3"INDICATES DRIVER TRAINING APPLIES,BUT GOOD STUDENT DOES NOT APPLY. "4"INDICATES BOTH DRIVER TRAINING AND GOOD STUDENT APPLIES. "X"INDICATES EXTRA VEHICLE. 5TH DIGIT-INDICATES NUMBER OF CHARGEABLE CITATION POINTS ASSIGNED TO THE VEHICLE. 6TH DIGIT-INDICATES NUMBER OF CHARGEABLE ACCIDENT POINTS ASSIGNED TO THE VEHICLE. CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: L_) I have and will maintain a certificate of consent of self-insure for workers'compensation,issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of El Segundo, Policy No. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# (\A I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pr ' ons the emerrt will automatically become void, Signature of Applicant Date Agreement for: Dated: • b.7 " I- Reviewed b 1