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PROOF OF INSURANCE (2018) CLOSED ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD1YYYY) i 1/3012017 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 poli'cy(les)must have ADDITIONAL INSURED Provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the germs and conditions of the Policy,certain policies may require an endorsen')et% A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). t 1 S PRODUCER K&K INSURANCE GROUP,INC. -d"dil(er� " Cheryi Pettibone - 1712 MAGNAVOX WAY irAMF Pte•. -.-.-. PO BOX 2338 _(��,•M E E t): 800-736,7358 a/c,No): 847-963-2M FORT WAYNE IN 46801 E-MIAll Ctre Pettibone@kandk)nsu nce-com __.__.._..�....�... ADDRESS! yr. .. ._m _ BVSURER(S)AFFORDIN'_Z�."-_®.'m..._ INSUREO .. '. G COVERAGE NAM# MEMBER NO: INSURER A Nationwide Mutual Insurance Company 23787 EL SEGt1ND0 BABE RUTH LEAGUE INSURER B:-Nationwide Life Insurance Company 66889 -'• DBA:El Segundo Babe Ruth INSURER C: 750 o: - 750 Sierra Street INSURER --� - SURER E: El Segundo,CA, 90245 INSURER F: -.._._.._w..... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TIVS IS TO CERTIFY TIIAT THE P'OLICIE'S OF INSURAN'C'E LISTED BELOW HAVE BEEN ISSUED TO THE IN'SU'RED NAMED AsovE 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 HE',REM IS SUBJFCI TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SI TOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR •• ADDL SUBR POLICY EFf= .FOMY EXP LTR 1 I�SN7 WVD Y17 TYPE OF INSURANCE POLICY NUMBER (MMIDOIYYYY) _IM VDDfYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE a $2,000,000 I.IACwE 10 HENI'E q... A w �CLAIMS MADE OCCUR X 02/Of12017 02/01/2018 PREMISES fen or=Oancar6 b 300.000 - Y RPG-278869 30 12:01 AM 12:01 AM !MED EXP(Any one person) $ 5,000 _-•- PERSONAL&ADV INJURY $2,... U 0000,, 000 GEN-L AGGREGATE LIMIT APPLIES PER: 'GENERAAGGREGATE $5r000,000 POLICY OPROJECT QLOC PARTICIPANT LEGAL $2,00D,000 --- PRODUCT Nq,,.._ OTHER LEGAL LIABILITY $2,000,000 ` AU'rOMOWLE LIABILITY COMBINED SiN(AE OMIT $1.000,000 I ANY AUTO BODILY INJURY(Per person) 0210 112 0 1 7 .I OWNED SCHEDULED 02/01/2018 """"•"`IL p' I AUTOS ONLY AUTOS RPG-276669-00 12:01 AM BODILY INJURY(Per accident) X HIRED X NON-OWNED 12:01 AM °j °OP '1y DAMAGE, AUTOS ONLY AUTOS ONLY ,(Per accident) .��__„•., UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIMB T CLAIMS-A4AOE AGGREGATE - _...,...__.�..DEDy I RETENTION .,..._.._•.,.a..,........._.�,__.. . .._..... WORK15R'S COMPENSATION YPER AND EMPLOYERS LIABILITY YIN !STATUTE I ,.MOTHER ANY P14OP7•kIE1010>ARINEWF.XECUTIVE E L.EACH ACCIDENT -.- •.�- 0FFiC:ERBMFWB6,R EXCt UDEO7 NIA (Mandatory in NH) EL,DISEASE-EA EMPLOYEE If yes,describe under .� DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 0210112017 02101/2018 Excess B PARTICIPANT ACCIDENT SPX-278671-00 12:01 AM 12;01 AM U ADBD Medical $2�,000�0^........ 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES[ACORO 101,Additional Remarks Schedule,maybe attached If more space is required) -THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED,BUT SOLELY WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED, Owner,manager or lessor of the premises where you conduct practices or games ON: $1000000 PER OCCURENCE42000000 AGGREGATE GEUAL ABUSE/MOL 3TAT1 , , R , , .. /1 •... RTIFiCAT HOLD'£R CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE:WITH THE POLICY PROVISIONS. City of El Segundo AUTHORIZED REPRESENTATIVE 350 Main Street E15egundo,CA 90245 !� ACORD 25(2016/03) Q 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: RPG-278669-00 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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(s): City of El Segundo its officers, officials, employees, agents, and volunteers. 350 Main Street El Segundo, CA 90245 RE: El Segundo Babe Ruth League 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 organization(s) shown in the Schedule, but only Section III —Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by 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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 CITY OF EL SE€sUNDO 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. I i—)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## (-01111 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 th e provisions or the agreement will automatically become void, Signature of AppliI cant, � �:t� .�� .. � Date Agreement for: Dated: " Reviewed by: 1