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PROOF OF INSURANCE (2018 - 2018) CLOSED C � CERTIFICATE OF LIABILITY INSURANCE DATE(MM)DD/YYYY) { ,,,,,.»-, I 11/27/2017 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(les)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 TACT PNM I Oxtt. (ohn M Tomlinson 16633oVentura Blvd. Ste. 1300 AM, PHONE Insurance Brokers, M 818) 836-580,0„ CpAit�,Nap:(,818) 721-5800 E-MAUL Encino CA 91436 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC H INSURER A:Nationwide Mutual insurance Cc 23787 INSURED (310) 478-5151 INSURERS:State Compensation Fund of CA 35076 Culver City Swim Club, Inc. INSURER C: 2800 Olympic Blvd., 2nd Fl INSURER D: Santa Monica CA 90404 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 6505 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. 1LTR TYPE OF INSURANCE LIMITS ADDLISUBR POLICY EFF POLICY EXP INSD I WVD POLICY NUMBER (MMIDDIYYYV)�(MMIDDIYYYM) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE')O RENTED CLAIMS-MADE I X I OCCUR Y 6BRPG0000006055100 08/05/2017 08/05/2018 PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLICY CGf D LOC PRODUCTS-COMP/OP AGO $ 1,000,000 07HER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ep irxiderit). ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY JURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PR AUTOS ONLY AUTOS ONLY tar w Y1'DAMAGE $ nt) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I �RETENTION$ $ ER B AND EMPLOYERS'LIABILITY 9220982-2017 11/07/2017 11/07/2018 ,ST ER WORKERS COMPENSATION Tp„&ITEOt YIN OF ICER/M EMBER EXCLUDE ECUTIVE N/A E L EACH - EMPLOYEE ACCIDENT $ 1,000,000 (Mandatory in NH) E L DISEASE $ 1,000,000 If yes,descnW un DFSCMPfION OFdOPERATIONS below EL DISEASE POLICY LIMIT $ 10000,000 A D & O 6BDNOOD00006056000 08/05/2017 OB/05/201B'Director: and g 1,000,000 Officers Per Claim A D & O 6BDN00000006056000 08/05/2017 08/05/2010 Directors and $ 1,000,000 Officers Aggr DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of 81 Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 _ / � I ©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: 6BRPG0000006055100 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(s) City of EI Segundo 350 Main Street EI Segundo, CA 90245 Ref: Culver City Swim Club, Inc. DBA:Alpha Aquatics Ref: CP#4397 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 0 Insurance Services Office,Inc.,2012 Page 1 of 1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) J 08/30/2017 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. IMPOR'T'ANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUDROGATI'ON IS W'AI'VED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certi'ficat'e does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandising Underwriting ADDRESS: ess: .......................info@ ports889rance-kk.comlAVAX....... .............1-26..........,... ) 0-459-5105 1712 Ma .. K&K Insurance Way Group, InceAD,c NnG Est; ro,N )! Fort Wayne IN 46804 .)1"INDUCER ........................_w OUSTOMERVD'; INSURER(S)AFFORDING COVERAGE NAIC# ..............................„.......................................... ...._w.,.,,.._�,.�.�. .,.,....................._W____..� INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Culver City Swim Club, Inc. INSURER B: DBA:Alpha Aquatics - --------w_ — •..... 2800 Olympic Blvd.,2nd FI INSURER C: Santa Monica,CA 90404 I INSURER D: A Member of the Sports,Leisure&Entertainment RPGI INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01093009 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, INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LA X COMMERCIAL GENERAL LIABILITY I XD mWVD 6BRPG0000006055100 t08/05/2017 1 05/2 8� EACH OCCURRENCE $1,000,000 CLAIMS_ X., 12:01 AM EDT 12:01 AM ZJAMAGE 10 REN'TEU. ............... ................................ �. (Eamm $1,000,000 MADE . . OCCUR PREMISES Occurre, ncej .............. ...�,__ MED EXP(Any one person) $5,000 _.............................................. w PERSONAL&ADV INJURY $1,000,000 .........,.......................................... GENERAL AGGREGATE GREGATE $5,000,000 ...................................... GEN'L AGGREGATE LIMIT ............. APPLIES PER: PRODUCTS—COMP/OP AGO $1,000,000 POLICY LOCPROFESS ,mmIT ,, $1 000,000 .......,.... OTHER. ,YtW�C:,'T LEGAL LIAR TOLPARBTIICIP............................................... ANTS A AUTOMOBILE LIABILITY 6BRPG0000006055100 08/05/2017 08/05/2018 COMBINED SINGLE LIMrI (Eaaccident) ..., ... $1,000,000 12:01 AM EDT 12:01 AM (,„ .pe..person) ANY AUTO BODILY INJURY Per X ONLYAUTOS ONLY ...X...�AUTOSULED ..BODILY INJURY(Per aocadent).........., ,mVmm......................................................................._._... OWNED AUTOS NON-OWNED „ AUTOS ONLY Per accidentDAMA ... X NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB .,, I�OCCUR EACH OCCURRENCE.... .............. EXCESS LIACLAIMS-MADE AGGREGATE DEDRETENTION .... .....W_.....,�. ................ W ,...... WOrfKERS COMPENSATION AND (EI EMPLOYERS'LIABILITY N/A ,,,,,,,,,,,I STATUTE�,._,,,,_I OTHER ANY PROPRIETOR/PARTNERI Y/N E L EACH ACCIDENT EXECUTIVE OFFICER/MEMBER ___.._................_.. .......................... ................. _ EXCLUDED?(Mandatory in NH) EA EMPLOYEE If yes,describe under DESCRIPTION E L—DIS1EASE- OF OPERATIONS below P11 O11 LICY LIMIT A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRP00000006055100 12:01 0AM EDT 2017 08/05/2018 2:01 AM EXCESS MEDICAL CMEDICAL $250,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Sexual Abuse or Sexual Molestation Liability-$1,000,000 each occurrence(included above)/$1,000,000 aggregate(included above) Legal Liability to Participants(LLP)limit is a per occurrence limit. Sport(s):Swimming Age(s): 12 and under, 13-15, 16-19 The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo,CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. (Owner/Lessor of Premises) (AUTHORIZED REPRESENTATIVE Coverage is only extended to U events and activities **NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9220982-17 STATE NEW INSURANCE SC FUND PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 9, 2018 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING NOVEMBER 7, 2018 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ALPHA AQUATICS 12100 WILSHIRE BLVD STE 1540 LOS ANGELES, CA 90025 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ALPHA AQUATICS IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 10, 2/018 2570 VIVE AUTHORIZED REPRESENPRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217