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PROOF OF INSURANCE (2018 - 2018) CLOSED ACC>R DATE fMIMX YYYIr) CERTIFICATE OF LIABILITY INSURANCE 08/1012017 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. I 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 CONTACT NAME: American Specialty Insurance S Risk Services,Inc. PHONE FAXAIN# xt)' 260-969-5203 fAIC Ncima 26G.969-4729 dba A.S.I.R.S.I.Insurance Agency WL ADZE 7609 W.Jefferson Blvd.,Suite 100 INSURER(S)AFFORDING COVERAGE NAICar Fort Wayne IN 46804 INSURER A: Arch Insurance Company 11150 INSURED INSURER B: ��..mm.ITITIT�IT� National Association of Sports Officials(NASO) INSURER C: 2017 Lathrop Avenue INSURER D, INSURER E: Racine WI 53405 INSURER F:WW._...... _ . COVERAGES CERTIFICATE NUMBER: 1001477561 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. Lin TYPEOFINSURANCE NDL POLICYNUMBER (WMdfDDNEYFYFYI IMM10D rl LIMRS COMMERCIAL GENERAL LIABILITY EA04OCCURRENC'E $ 1,000,000 ..,�CLAJMS-MADE FROCCUR I'bAMETOR'E�Hl'E .s.. 1'000,000---- .if1,�i".�..i'4r�. 1..�+II )........... _!go ExP„LArry one r�araen) s Excluded A Y SBCGL0279600 08/01/2017 08/01/2018 I PERSONAL a ADV INJURY $ 1.000.000 GENt AGGREGATE LIMIT APPLIES PM, GENERAL AGGREGATE S 5.000,000 PRO- JECT RO• POLICY El JEGT E-1LOC PRODUCTS...-COM_P.I_Oa.P_..A._GG S 5,000.000 ...... x OTHER: OFFICIAL s AUTOMOBILELIABILIY COMBINED SINGLE LIMIT i Aar��ll ANYAUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per ao 3denl) S .`._,I AUTOS WAYAUTOS HIRED NON-OWNED PROPERTY OAIMAGE i AUTOS ONLY AUTOS ONLY rPurw Accident) i UMBRELLA LIM M OCCUR EACH OCCURRENCE S 2.000.000 A X EXCESS UAB mmms4mw N N SBFXS0044400 08/01/2017 08/01/2018 AGGREGATE S 2,000,000 W J J RETENTIONS yi WORKERS COMPENSATION J PER � N FORTH AND EMPLOYERS'LIABILITY YIN I STATUTE ER ANYPROPRIETORIPARTNERIEXECUrIVENIA E.L.EACH ACCIDENT S OFFICERMEMBEREXCLUDED7 (Mridalory In NH) EL DISEASE-EA EMPLOYEE $ H 1.deslalbo umlor _ _- O�CRIPTI Ol l OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Addibmal Ramadu Schedule,may be aDachad N mon space In required) -Coverage applies to JOHN ZIELLO.704 CAMINO REAL,REDONDO BEACH,CA 90277. -Other Named Insured:National Association of Sports Officials(NASO)8r NASO-member officials,including officials enrolled by associations,contracted with NASO, CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO.ITS OFFICERS.OFFICIALS,EMPLOYEES, AGENTS,AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCR®teD POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS 350 MAIN STREET AUTHORED REPRESENTATIVE EL SEGUNDO CA 90245 m 1955-2015 ACORD CORPORATION.AN reserved. ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: AC ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAY®INSURED American Specialty Insurance&Risk Services,Inc. National Association of Sports Officials(NASO) POLICY NUMBER 2017 Lathrop Avenue SBCGLO279600 CARRIER NAICcoDE I Racine,WI 53405 Arch Insurance Company 11150 EFFECTIVE DATE: 08!0112017 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE-Certificate#1001477561 -Other Named Insured(conrd):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 CG 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 act/$50,000 Annual Aggregate per official/assignor ACORD 101 (2008101) ®2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: SBCGLO279600 COMMERCIAL GENERAL LIABILITY CG 2010 0413 ADDITIONAL I _ OWNERS, L 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 350 Main Street EI 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 person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: With damagerespect t "personal liability orenbd i dverti advertising injury" This insurance does not apply to"bodily injury" or 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 1. The insurance afforded to such additional injury or damage arises has been put to its insured onlyapplies to the extent permitted b intended use by any person or organization PP Pe Y 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. CO 2010 0413 0 180 Properties, Inc.,2004 Page 1 of 2 O 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: 1. Required by the contract or agreement;or CO 2010 0413 0 ISO Properties, Inc.,2004 Page 2 of 2 O 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 1103 Page 1 of 1 1 S E Insurance Bill INSURANCE GROUP Renewal Personal Auto Policy PCS,Bax 8041,rvahmiCreek,CA 94596-8041 Civil Service Employees Insurance Company PHONE:800-282-0848 * wrsw eserrsurance com Notice Date: 10/06/2017 Bill To: Agent BICHLMEIER INSURANCE SRVS INC caryb@bisins.com Address Code 41644-41644 730 S.PACIFIC COAST HWY#201 ZIELLO,MARY P AND JOHN E REDONDO BEACH,CA 90277 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Phone: 800-888-7187 Fax: 310-540-2215 Insured: ZIELLO,MARY P AND JOHN E Policy: CAA8002278 Term: 11/11/2017 to 05/11/2018 For detailed information regarding your coverage,please refer to your declaration pages. Otherwise,for any insurance needs or questions,please contact your independent agent. . Billing Activity as of..10/06/2.0.1.7................................................................................rr__... — Balance From Totni Policy Installment Fee Amount Current Minimum Premium Prior Term Premium To Date Received Balance Due by: 11/11/2017 $0.00 $791.16 $0.00 $0.00 $791.16 $270.87 Payment Plan Options To pay the current balance in full: To pay the premium in installments: Return the payment coupon with your check for $791.16 Due 11/11/2017 $270.87 Due 02/09/2018 $137.59 Or pay by phone or via the internet. See reverse side for details. Due 12/11/2017 $137.59 Due 03/11/2018 $137.52 If you make changes to your policy resulting in premium Due 01/10/2018 $137.59 adjustments,you will receive an updated installment schedule. Each installment includes a$6.00 service charge. This is your renewal billing. Your policy renewal,which indicates your coverages and limits,is enclosed. Your coverage will not continue unless we receive the minimum premium due before 12:00 a.m.Standard Time on 11/11/2017. See reverse for important information regarding CSE's installment payment plans. Keep top portion for your records .................................................................................................................... Insured Bill Please detach and return with your payment Allow five days for delivery. CSE Insurance Group Policy Number: CAA8002278 Effective: 11/11/2017 Notice Date: 10/06/2017 Insured's Name: ZIELLO,MARY P AND JOHN E To Pay In Full Minimum Due Due Date F Amount Enclosed $791.16 $270.87 11/11/2017 Make check payable to Civil Service Employees Insurance Company. Send check with policy number to: CSE Insurance Group, P.O.Box 60289,Los Angeles, CA 90060-0289 Pay by phone:888-645-2586. Pay on-line:MyCSEpolicy.com. Automated payment.see reverse 04k800227800600011711111711110000797160000270872 Personal Auto Policy Installment Payment Plans EFT(Electronic Funds Transfer)Automatic Payment Plan Each installment equals one-sixth of the full-term premium if EFT 6-Pay Plan or one-twelfth of the full-term premium if EFT 12-Pay Plan . Each month of the policy term the company automatically debits the insured's checking account for the installment amount. Each installment includes a service charge. The insured authorizes the company to debit any other premium due when Processing an EFT payment.The company notifies the insured of any change in debit amount at least 10 days in advance of the EFT transaction. The company assesses a service charge for any EFT transaction denied due to insufficient funds. The company may cancel the policy due to insufficient funds.To start or stop EFT or to make any other change regarding your EFT plan,submit a signed request to the company at least 60 days prior to the next renewal date. Contact your agent for more details about the EFT Automatic Payment Plan. Five Payment Installment Plan The first installment equals one-third of the fUll-tCTM premium. Each of the remaining four installments equals one sixth of the full-term premium.The insured pays the first installment upon issuance of the new business or receipt of the renewal notice.For the remaining four installments the company bills the insured 15 days prior to the due date in 30-day intervals.Each installment includes a service charge.If any first payment is less than the full-term premium,the company implements the Five Payment Installment Plan and assesses a service charge for the first payment and each subsequent payment for the policy term.The company assesses a service charge for any check returned by the bank due to insufficient funds.If non-payment of premium results in a cancellation notice and payment is not received by the cancellation effective date specified in the cancellation notice,the company notifies any loss payee or additional insured that the policy has been cancelled for non-payment.Contact your agent for more details about the Five Payment Installment Plan. Online and Telephone Payment Services Pay premium online or by telephone 24 hours a day/seven days a week with a Visa, MasterCard, Discover Card, or American Express credit card, a participating Star Systems debit card, a participating Star Systems ATM card with debit feature, or an electronic check.To pay online visit MyCSEpolicy.com.To pay by phone,call 1-888-645-2586.A payment made before 11:00 am Monday through Friday excluding holidays posts the same day. A payment made after 11:00 am or at any time on a Saturday, Sunday, or holiday posts the next business day. Payment must be at least the minimum amount due. Policy must be active. Visa, MasterCard,Discover Card,and American Express will assess a convenience fee for each payment made by their card.LSE's online and telephone services are made possible by Wells Fargo Bank. Automated Bill Pay Payments CSE accepts automated payments such as Bill Pay made through your bank or other bill paying vendor. Send your payment with your policy number to CSE Insurance Group, P. O. Box 8041, Walnut Creek, CA 94596-8041. Using any other address for automated payment, or failing to include your policy number with your payment, may delay posting of your payment.Delayed posting of your payment may lead to cancellation of your policy for non-payment. Civil Service Employees Insurance Company Post Office Box 60289 Los Angeles CA 90060-0289 EVIDENCE OF INSURANCE COVERAGE Insurance identification cards are provided below. Please retain one card in the referenced vehicle. An additional card is available as required by some states for vehicle registration. CSE provides insurance information electronically to the CA,AZ and NV Department of Motor Vehicles. AV*AMb WO California Proof of Automobile Aft owl California Proof of Automobile Liability Insurance Liability Insurance INSURANCE GROUP NAIC 10693 INSURANCE GROUP NAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins,com caryb@bisins com 704 CAMINO REAL 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address 730 S PACIFIC COAST HWY#201 730 S PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277 Policy Number: CAAB002278 Policy Number: CAA8002278 Effective Date: 11/11/2017 Effective Date: 11/11/2017 Expiration Date: 05/11/2018 Expiration Date: 05/11/2018 Ph.800-888-7187 Fx310-540-2215 Ph.800-888-7187 Fx310-540-2215 Year/Make/Model VIN Year/Make/Model VIN 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 .............__.................... .,................................................................. California Proof of Automobile California Proof of Automobile Liability Insurance Liability Insurance INSURANCE GROUP NAIC 10693 INSURANCE GROUP NAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins com caryb@bisins,com 704 CAMINO REAL 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address 730 S PACIFIC COAST HWY#201 730 S. PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277 Policy Number: CAAB002278 Policy Number: CAA8002278 Effective Date: 11/11/2017 Effective Date: 11/11/2017 Expiration Date: 05/11/2018 Expiration Date: 05/11/2018 Ph.800-888-7187 Fx310-540-2215 Ph.800-888-7187 Fx310-540-2215 Year/Make/Model VIN Year/Make/Model VIN 2016 FORD EDGE SEL 2FMPK3J91GBB60321 2016 FORD EDGE SEL 2FMPK3J91GBB60321 Civil Service Employees Insurance Company Civil Service Employees Insurance Company P.O. Box 8041 P.O. Box 8041 Walnut Creek CA 94596-8041 Walnut Creek CA 94596-8041 To report a claim,call your AGENT or 1-800-282-6848. To report a claim,call your AGENT or 1-800-282-6848. For other insurance information contact your AGENT. For other insurance information contact your AGENT, This insurance complies with CVC§16056 or§16500.5. This insurance complies with CVC§16056 or§16500.5. Civil Service Employees Insurance Company Civil Service Employees Insurance Company P.O. Box 8041 P.O. Box 8041 Walnut Creek CA 94596-8041 Walnut Creek CA 94596-8041 To report a claim,call your AGENT or 1-800-282-6848. To report a claim,call your AGENT or 1-800-282-6848. For other insurance information contact your AGENT. For other insurance information contact your AGENT, This insurance complies with CVC§16056 or§16500.5. This insurance complies with CVC§16056 or§16500.5. Insured Copy CSERenewal Personal Auto Policy INSURANCE GROUP Civil Service Employees Insurance Company P.O.Box 8041,Walnut Creek,CA 94596-8041 To continue coverage, please send in your payment by 11/11/2017.Thank you PHONE:800-281-6848 www.eseinsurance.com for insuring with CSE. Policy# Policy Term (begins and ends at 12:01a.m.Standard Time) Notice Date CAA8002278 From 11/11/2017 to 05/11/2018 000 10/06/2017 Named Insured and Address Agent BI HLMEIER INSURANCE SRVS INC caryb@bisins.com ZIELLO, MARY P AND JOHN E 704 CAMINO REAL Address Code 41644-41644 REDONDO BEACH, CA 90277-4317 730 S. PACIFIC COAST HWY#201 REDONDO BEACH, CA 90277 Phone 800-888-7187 Fax 310-540-2215 Vehicles are covered pursuant to the terms and conditions of the contract Terri Annual Stated Deductible Veh ST RBG Year Make/Description Serial Number Use Mileage Symbol Amount OTC Col Class 004 CA 999 12 FORD TRANSIT C NM0KS9CN9CT11346 B 12,000 21/23 N/A 500 500" 84D100 005 CA 999 16 FORD EDGE SEL 2FMPK3J91GBB60321 P 10,500 30/21 N/A 500 500* 88D100 Insurance is provided where a premium is shown for the coverage Coverage Limits of Liability Premiums Ea Person Ea Occurrence Veh.004 Veh.005 FORD FORD Bodily Injury $ 25,000 $ 50,000 $ 72.50 $ 59.00 Property Damage $ 25,000 $ 65.00 $ 53.00 Uninsured Motorist BI $ 25,000 $ 50,000 $ 15.00 $ 12.20 Underinsured Motorist BI Limits included in Uninsured Motorist BI Limits above $ 6.10 $ 500 Other than Collision-See deductible limit above $ 29.60 $ 37.00 Collision-See deductible limit above $ 196.90 $ 188.50 *Uninsured Motorist-Waiver of collision deductible $ 9.80 $ 9.80 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 $ 013 $ 0.13 Total By Vehicle $ 410.78 $ 380.38 Good Driver Discount Applied Total Policy Premium $ 791.16 *Uninsured Motorist-Waiver of collision deductible applies to those vehicles that have a premium shown. Insured Billed Continued on next page CITY OF L SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: ICOMPENSATION IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINALPENALTIES FINESAND CIVIL ($100,000), IN ADDITIONI' DAMAGES AS PROVIDED FOR IN 7 , INTEREST, AND ATTORNEYS FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: U I have and will maintain a certificate of consent of If-insure forworkers' 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 have and will maintain work 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. Myworkers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone I certify that, in the perfonnance of the work set forth in the agreement with the City of El Segundo, I will not oy 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 provisions Labor § 3700_ I must immediately comply with thos ro i agreement will automatically become void. r '' Signature of Applicant .� Date Print Name jQ Agreement for: Dated Reviewed y: