PROOF OF INSURANCE (2017 - 2018) CLOSED 0 DATE(MMMDfn-M
A TIFF TE F LIABILITY INSURANCE
I 08/10/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS PICK 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 IINSURER(S), AUTHORIZED
RE'PR'ESENTATIVE 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 CONTACT
NAME:
American Specialty Insurance&Risk Services,Inc. PHONEFAX
Air Na.Eats: 250-969-5203 APC,No): 260-969'-4729
dba A.S.I.R.S.I.Insurance Agency E-MAADDRESS:
IL
7509 W.Jefferson Blvd.,Suite 100 INSURERIS)AFFORDING COVERAGE, NAICO
Fort Wayne IN 46804 INSURE'RA: Arch Insurance Company 11150
INSURED INSURERS:
National Association of Sports Officials(NASO) INSURER c:
2017 Lathrop Avenue INSURERD: ppp
INSURER E:
Racine WWI 534055' INSURER F:
COVERAGES CERTIFICATE NUMBER: 11001477551 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 CONTRACTOR 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 POLIOIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY ''AID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS
LTR INSO WVn POLICYNUMBER IMMPDDIYYYYh'!IMIUtrion1!
" m
X COMMERCIAL GENERAL,LIABILITY EACH OCCURRENCE 1,000,000
-15MA{SE
CLAIMS-MADE �OCCUR PREMISES(Ea RENTED
$ 1,000,000
MED EXP(Any one person) $ Excluded
A Y SBCGL0279600 08/0112017 08/0'1/20'18 PERSONAL SADV INJURY $ 1,000.000
GEICL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000
POLICY JECT �LOC PRODUCTS-COMPIOPAGG $ 5,000,000
X OTHER: OFFICIAL $
A'U'TOMOBILE LIABILITY COMBINED SINGLE LIMIT $ i
Me accident) I
ANY AUTO BODILY INJURY(Per Person) $
OWNED SCHEDULED BODILY INJURY(Pear accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTYDAMAGE $
AUTOS ONLY AUTOS ONLY deer accidents
$
UMBRELLALIAB X OCCUR' EACH OCCURRENCE '$ 2,000,000
A X EXCESS LIAS CLAIMS-MADE N N SBFXS0044400 08/01/2017 08101/2018 'AGGREGATE $ 2,000,000
DED I I RETENTIONS $
WORKERS COMPENSATION � �
AND EMPLOYERS'LIABILITY YIN PSTATUTE OTERFf-
ANYP'ROPRIETOR/PARTNERIEXECUTIVEN A E.L,EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $
0Ues.describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
P E
`DESCRIPTION OF OPERAI7ONS LOCATIONS I YEHICL S (ACORD 901,Additional Remarks Schedule,maybe attached If more apace is required)
-Coverage applies to JOHN ZIELLO,704 CAMINO REAL,REDONDO BEACH,CA 90277.
I
i
-Other Named Insured:National Association of Sports Officials(NASO)5 NASO-member officials,Including officials enrolled by associations,contracted With
NASO',
CERTIFICATE HOLDER CANCELLATION
THE CITY OF EL SEGUNDO,ITS OFFICERS,OFFICIALS,'EMPLOYEES,
AGENT'S,AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE,
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN STREET
AUTHORIZED REPRESENTATIVE
EL SEGUNDO CA 90245
I
0 1908-2015 ACO'RD CORPORATION. All rights reserved''.
ACORCD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID.
LOC#:
ACOWE) ADDITIONAL REMARKS SCHEDULE Page I of I
flk�
AGENCY NAMED INSURED
American Specialty Insurance&Risk Services,Inc, National Association,of Sports Officials(NASO)
POLICY NUMBER 2017 Lathrop Avenue
SBCGiL0279600
CARRIER NAIL CODE I Racine,WI 53405
Arch Insurance Company I 11150 EFFECTIVE DATE. 08/01/2017
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE-Certificate#1001477661
Other Named Insured(contd):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.
-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 CIS 2010 Additional Insured-Owners,Lessees or Contractors-Scheduled Person or Organization,but only with respect to the JOHN
ZIELLO.
Unintentional Errors&Omissions,$50,000 each wrongful actl$50,000 Annual Aggregate per officiallassignor
ACORD 101 (2008101) t 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: SBCGI-0279600 COMMERCIAL GENERAL LIABILITY
CG 20100413
ADDITIONAL INSU�RED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED 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
360 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 11 — Who Is, An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured the p'erson(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 04 13 @ ISO Properties, Inc., 2004 Page 1 of 2 01
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:
11. Required by the contract or agreement; or
CG 2�O 10 0413 0 ISO Properties, Inc., 2004 Page 2 of 2 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
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 of this,Policy remain unchanged.
Company:Arch Insurance Company
Endorsement Number:08
Policy Number: SBCGL0279600
Named Insured: National Association of Sports Officials
Endorsement Effective Date: 08/01/17
President
00 ML0207 00 11 013 Page 1 of 1
Insured Copy
CSE Renewal Personal Auto: Policy
aNsuas+r CE GROUP Civil Service Employees Insurance Company
a
AO.BoxNE.9001„ 2.68 r Crept,e1 irrsad dAa! To continue coverage,please send In your ppayment by 05/1112017.Thank you
PHONE.dAA-292.9999 " mw^rn.crrinrwrrr rae.srrra for insuring with CSE.
Policy# Policy Termbe i'ns and ends
g ds at 12;01a,m.Standard Ti. v
mei Notice[late
CAA8002278 From 05/11/2017 to 11/11/2017 000 0410512017
Named Insured and Address Agent BICHLM iERS.INSURANCE SRVS .
. INC
cMb@b
com
ZIELLO,MARY P
704 CAMINO REAL Address Code 4164441644
REDONDO BEACH,CA 90277-4317 730.5.'PACIFIC COAST HWY€/201
REDONDO BEACH,CA 90277
Phone
0
Vehicles are covered pursuant to the terms and conditions
Fax 310-540-2215
o ditioof the contract �
"Perri Annual Stated Deductible
Veh ST RBG Year Make/Description aerial Number Use Mileage Symbol Amount OTC Cad Class
004 CA 989 12FCORDTRANSITC NM0KS9CN9CT11346 B 12,000 21123 N/A 500 500' 84DI00
005 CA 999 16 FORD EDGE SEL 2FMPK3J91GSB60321 P 10,500 30123 IVDA, 500 500" 8813100
Insurance is provided where a premium is shown for the coverage
Coverage Limits of Liability Premiums
Ea Person Ea Occurrence Vehs.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
Roadside Assistance Up to 100 miles towing $ 5.00
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 premiums shown.
Insured Billed
Continued on next peg's