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PROOF OF INSURANCE (2017) CLOSED AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) '%� 12/20/2016 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). PRODUCER NAME!CONTACT „ .., FAX Lockton Insurance Brokers, LLC-Encino PHONE E Ext); FA NAME! Jo M Tomlinson 16633 Ventura Blvd., Ste. 1300 C,No), E-MAIL '.... Encino CA 91436 ADDRESS: � NAIC# INSURER(S)AFFORDING COVERAGE INSURER A:Nationwide Mutual Insurance Cc 23787 INSURED INSURER B: Culver City Swim Club, Inc. INSURER C: 2800 Olympic Blvd., 2nd Floor INSURERD: Santa Monica CA 90404 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 3801 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 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS, LTR, _ dbbl. WF1M p YFYY1 I POLICY EXP rr INS n„ POLICYNUMBER ( [SDNYYYI LIMITS N R TYPE OF INSURANCE � II A X COMMERCIAL GENERAL LIABILITY ' CLAIMS-MADE II X l OCCUR Y 6BRPG000000S890100 08/05/2016 08/05/2017 DREW E,§�Ep ccurr ry ey $ 1 300,000 l 0,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 11000,000 GENERALAGGREGATE $ S'000,000 X E EN'LAGGRiGAT LIMIT APPLIES PER: .. POLICY F=RCC'- I „ LOµ PRODUCTS -COMP/OP A G G $.. 1,000,00---0 01"W"R $ AUTOMOBILE LIABILITY Na D SlNGLE LIMIT (Ea pp 1d„ ) - '$ 1,000,000 A ANY AUTO Y 6BRPG00000OS890100 08/05/2016 08/05/2017 BODILY INJURY(Per person) $ X AUTOS ONLY X SCHEDULED (BIODI RIINJURAY(Per accident AUTOS OWNED 5 HIRED NON--OWNED i x (Per AUTOS ONLY AUTOS ONLY + $ Is UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB �CLAIMS-MADE AGGREGATE $ DED RETENTI ON$ ..,,... $ WORKERS COMPENSATION PER 01 H- AND ' AYPRO RIIETOR PL RTNEE EXECUTIVE YIN E L(EACH-STATUTE ACCIDENT ER $ OFFICER/MEMBER EXCLUDED? NIA E L DISEASECEA (Mandatory in NH) EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ $ $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schad be attached if more space is required) The City of El Segundo, its officials, and employees are included as additional insured but only as respects to claims arising out of the negligence of the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. P (AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 POLICY NUMBER: 6BRPG0000005890100 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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(R) City of El Segundo 350 Main St. El Segundo, CA 90245 Re:Culver City Swim Club, Inc. DBA:Alpha Aquatics Cp#3054 I 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 is added to Section organization(s) shown in the Schedule, but only with III—Limits Of Insurance: respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or"personal and advertising injury" caused, required by a contract or agreement,the most we will in whole or in part, by your acts or omissions or the pay on behalf of the additional insured is the amount acts or omissions of those acting on your behalf: of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement;or or 2. In connection with your premises owned by or 2. Available under the applicable Limits of rented to you. Insurance shown in the Declarations; However: whichever is less. 1. The insurance afforded to such additional This endorsement shall not increase the applicable insured only applies to the extent permitted by Limits of Insurance shown in the Declarations. law;and 2. If coverage provided to the additional insured is 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 26 0413 ©Insurance Services Office,Inc.,2012 rage 1 of 1 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: (_) 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. C_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance Y 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# 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 nner so as to become subject to the workers' compensation laws of California, and agree that, if I should I a subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t e provisio or the agreement will automatically become void. Signature of Applicant � Date 7- 1 Agreement for: � 1 U Dated: Reviewed by: _ A 1