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PROOF OF INSURANCE (2017) CLOSED )ATE;MMDDM YI)C ERTIFICATE OF LIABILITY INSURANCE 1 09/10/16 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 Ileu of such endorsement(s). P CONTACT PRODUCER NAME: 9 Agency IW . G,.tiitr. " PAX Sterlin A enc Insurance Services PHONE 800.991-'2'00'2 a 800-991-2024 P.O.Box 12439 MA"L Wsteriirlg5teriun a erAC .com Marina Del Rey,CA 90295 INSURERS)AFFORDING COVERAGE NAIC a INSURER A:Scottsdale Insurance Company INSURED INS_URER B_ Ser IN... : iu Boerica 9 INSURER C: DBA:Jaguar Tennis Academy INSURER D: _.. .. .... ....... INSURERE. ...._... .,_.....W.,, „,,,, ....... ..............� INSURER Fmm............,� COVERAGES CERTIF'ICAT'E NUMBER: 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILX TYPE Of dN'SURANC'E A"ti191 '�.'�"_-._.._. ... P PR X0..1 1"11XP LIMITS POLICY NUMBER IMMIDDdYy' i IMMSrk X COMMERCIAL GENERAL LIABILITYEACHOCCURRENCE S 2,000 000 A x CPS2051988 9/11/16 9/11/17 _UAMAGETORENTED _ tl CLAIMS-MADE OCCUR '_P�RE,.M!cSES'tCe S 100,000 ..,. _µ MED EXP(Any one Derson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 u GEN'L AGGREGATE CT APPLIES PE GGREGA E 00 Q,QQQ POLICY PRODUCTS S 1, 0,000 CTF � .. s AUTOMOBILE LIABILITY 60WB FDSINGLEUMIT ANY A S - -� AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) S person) OWNED SCHEDULED I S HIRED +. NON-OWNED PROF+ R,.Y,AMAGE.- AUTOS ONLY AU r05 ONLY (Per sc4grap S s UMBRELLA UAB II OCCUR EACH OCCURRENCE _... .......... 5,,,, _. .. .... ...... , EXCESS LIAR CLAIMS-MADE AGGREGATE S .,., . _RED I I RETENTIONS -,. _.... .,_. $ NMORXERO COMPENSATION , UTE I I ER AND EMPLOYERS''LIABILITY YIN - ANYOROP"IE'TOMPARTNERI'EXECUTIVE OFFICEWEMSEREXGL,UDEFa? NIA _E.L EACH ACCIDENT $ (Maodatosy In NHI E.L DISEASE-EA EMPLOYEE S It yyes,describe under ....•°°°° DESGRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additions"Remarks Schedule,may be attached H more space Is required) CERTIFICATE HOLDER �CANCELLATION The City of El Segundo, its officers, SHOULD ANY OF TH *FN LICIES BE CANCELLED BEFORE offlclals,employees, a ents, and volunteers THE EXPIRATION ATCE WILL BE DELIVERED IN g ACC 'RD NCE W H THE as Additional Insured 401 Sheldon Avenue ADr DRE ENT'ATIVEEI Segundo, CA 90245 /I ©1988-20RATIO All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of A CPS2051988 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS,S, LESS ES O CONTRACTORS - COMPLETED 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 Organization) ): tions City of El Segundo, its officers, officials, employees, Recreation Park agents and volunteers ,401 Sheldon St. El Segundo, CA. 90245 Informat on required to complete this Schedule if not shown above, will be shown in the Declarations, Section II —Who Is An Insured is amended 1-6 include as an additional insured the person(s) or organiza- tion(s) shown in the Schedule, but only with respect to 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 C ISO Properties, Inc., 2004 Page 1 of 1 p G IC U California Evidence of Liability Insurance Evidence of Insurance 1-80o4ft-3000 ewdoo.00im GEICO GENERAL INSURANCE COMPANY Here are your Evidence of Liability Insurance PO BOX 509090 SAN DIEGO,CA 92150w90 C `'''';. !,'' Cards. One card must be carried in the proper NAIC Code: 35882 insured vehicle. Proof of insurance is required to register or renew the registration of your Policy Number Effective Dike Expiration Date vehicle. A law enforcement officer can ask you 4277475929 02-13-1,7 08-13-17 to prove that you have liability insurance meeting Year Make Model Vehicle ID No. the basic requirements of California law. 2000 FORD F250 PQ,'"! 1 FTNX20FXYEA26508 A violation of these requirements can result in a fine Insured: of up to: VIRGINIJA KIRKILIENE $1,000 for the first time SERGIU BOERICA $2,000 for additional times 906 E IMPERIAL AVE Also, a Judge can have your vehicle impounded. APT 1 False proof of insurance may result in a fine up to EL SEGUNDO, CA 90245-2519 " $750 and 30 days in prison. The coverall a provided by this policy meets She rninimurn requiremanls of seclions 16056&16500 5 of the California Due to space limitations on the ID card, only the Vehicle Code,minimum habilily limils prescribed by law Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page,which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. What to do at the time of an accident. - Do not admit fault. - Do not reveal the limits of your liability coverage to anyone. - Exchange contact information;get year, make, model, plate number, insurance carrier and policy number of all involved. Also, identify witnesses and collect contact information. - Contact the police or 911 if applicable. - Contact GEICO by calling 1-800-84i-3000 or visit gelco.com to report the accident. U-4-CA(11-09) 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. . . . . (_J 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# I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not ernploy 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 Ao the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thoserovisi the agreement will automatically become void. �mm..._ .... ...m.. Date j Signature ppp..�.......nt _._ wW....... - .. ._.__....... i natureVofA... lican..........�.. ...........ww�._„ ....ww.......,,,. ,_. ............ ,, ,,,,,,, _...._.�....�..�. "''�� .� � �� P r,..., d` +" ✓ ...mod' �„. Agreement for Dated; Reviewed by: j ��k. ,M 1