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PROOF OF INSURANCE (2018 - 2019) CLOSED ELEWIS2 A �� >o CERTIFICATE OF LIABILITY INSURANCE I�`o-o ....D,1 mmmmm„ _,D „ ATE(MMID ( ......... ............................................................................... w.... .... w W ... .................. 1,7 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:mmmmlfm the,.,......,.rtificate....hold...........is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUB' cert holder ' UBROGATION 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'; Edie Lewis Alliant Insurance Services Inc. PHONE509F'AX 343-9590 818 W Riverside Ave Ste 800 (Aro,No,Ent); (AJC,N'op Spokane,WA 99201 EMIL edle.Iewls all ll'an't.cDrn P ADDRESS: INSURERS)AFFORDING COVERAGE NAIC N INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B: Leap Sports Academy LLC INSURER C: 435 Lomita St INSURER D: EI Segundo,CA 90245 INSURER E: INsuRE'R F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ........ .... ..... ...._ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH11 E POLIC11 Y 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 I.NSP I_�P ( POLICY EXP ,N�,,, -- _ — _ POLICY1811 DD„/YYYY,)„1MMIDD/Y1'YY),,, LIMITS IN. TR 000,000 R TYPE OF INSURANCE POLICY NUMBER M„ EACH OCCURRENCE '.S 1 A X COMMERCIAL GENERAL LIABILITY OCCUR X PHPK1624022 04/27/2017 04/27/2018 IDHM MItiE AGE 1 "RE clsITdrr`rrnr�a) $ 100,000 CLAIMS-MADE x MED EXP(Any one p&son) $ Excluded PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 X ROLIC'd1 LOC PRODUCTS-COMP/OP AGG S 2,000,000 JECI=6'O 07H EP AUTOMOBILE ......... ,,,,., . ILE LIABILITY G��^C7Q�,V'.?�'I�I�m i�SIN'GI,EI.,IMIT . ............... 4ffii3n* ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED F�'RO�PER'1T" DAMAGE $ AUTOS (IPor ai svoenl) S UMBRELLA LIAB OCCUR ......... .... .... EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED ., ...RETENTION$ .... ...., .... . ..,.., .... .....,,.,,, $ WORKERS COMPENSATION PER 01 H- i AND EMPLOYERS'LIABILITYY/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached'd more space is required) The City of EI Segundo,its officers,officials,employees,agents,and volunteers are Additional Insureds regarding premises leased to the Named Insured. ...........................................­.................. ........... m.................................................1,...................... w__w_ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE f EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City o 350 Main f ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo,CA 90245 ............. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PI-AS-010 (04/04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED: OWNERS AND / OR LESSORS OF PREMISES, LESSORS OF LEASED EQUIPMENT, SPONSORS OR CO- PROMOTERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This policy is amended to include as an additional Insured any person or organization of the types designated below, but only with respect to liability arising out of your operations: 1. Owners and/or lessors of the premises leased, rented, or loaned to you, subject to the following additional exclusions: a. This insurance applies only to an 'occurrence" which takes place while you are a tenant in the premises; b. This insurance does not apply to"bodily injury" or"property damage" resulting from structural alterations, new construction or demolition operations performed by or on behalf of the owner and /or lessor of the premises; c. This insurance does not apply to liability of the owners and/or lessors for"bodily injury" or "property damage" arising out of any design defect or structural maintenance of the premises or loss caused by a premises defect. With respect to any additional insured included under this policy, this insurance does not apply to the sole negligence of such additional insured. 2. Lessor of Leased Equipment, but only with respect to liability for"bodily injury", "property damage" or "personal and advertising injury"caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s) subject to the following additional exclusions: a. This insurance does not apply to any'occurrence"which takes place after the equipment lease expires. 3. Sponsors 4. Co-Promoters Page 1 of 1 PRODUCER AUTO INS SPECIALISTS-CA 043896 09 PO BOX 6507 ARTESIA, CA 90702-6507 Aft M E R C U RY AUTOMOBILE POLICY DECLARATIONS TELEPHONE:(800)493-7879 INSURANCE COMPANY IMPORTANT COVERAGE EXCLUSION POLICY NUMBER POLICY PMOD APPLICABLE TO ALL COVERAGES, INCLUDtNG BUT NOT LIMITED TO,LIABILITY 0401 09 170043777 IIW&102�101 1201812:01AM�10()IJ�()l/201812�oiAM'i AND UNINSURED MOTORISTS,PROVIDED NOW OR LATER. It is agreed that the InSuviLirkoe afforded by this policy PERSONS INSURED shall not apply nor arxm,e to the benefit of any insured or any NAMED INSURED third perty claimant wl,vo any motor vehicle is being used w KIMBERLY L WAKEFIELD operated by a person listed"low regardless of where the per-.mo mside-i o�wholint 11se ijer,�ogt is kccilvAed Iv fllivn DRIVERS KIMBERLY L WAKEFIELD JORDA,N ASBEE BENJAMIN WAKEFIELD MAILING 435 LOMITA ST ADDRESS EL SEGUNDO, CA 90245-4054 CAR YEAR Vit"CLE,DESCRIPTION SIA 641,NUMBER COST ON VAiU( NEWAI$Cb: pUpCH DA'T'E', P�CIP 1 206 INFINITI FX35 AWD UTL 4X4 4D JNRAS08WB4X221592 U 1212016 I2 2017 HYUNDAI SONATA SPORT/LIM SED 4DR 5NPE34AF8HH496283 N 0812017 �CARLP Al-UN WHO LOSS PATELU W11,AOMHUNAt NItNES" E%A0,LOSS PAVEAND AWRILONALL JNTOKSM KAI :ARAGIIW ADDRESSES A=AND RMSTEAED OWNERS IR01 OTHER THAN THOSE LISTED AWVE. 2 LP SCHOOL FIRST CU P.O. BOX 11547 GANTA ANA CA 92 1 N I Coverage applies only if premium charge is listed below. Coveragell-emits are subject to all policy terryis, COVERAGES LIMfTS OF LIABILITY BILITY PRENMUMS NON-FACTORY EQUIlIPMENT BODILY INJURY UABILITY $100,000 EACH PERSON $ $00,000 EACH ACCIDENT CARI CAR2 CAR ITEMS INSURED AND AMOUNTS OF 84 81 INSURANCE FOR EACH ITEM ARE STATED PROPERTY DAMAGE LIABILITY 1(jo,0()0 EACH ACCIDENT 98 HEREIN_ ITEMS INSURED ARE SUBJECT TO UNINSURED MOTORISTS THIF DEDUCTIBLE. BODILY INJURY LIABILITY $100,000 EACH PERSON $ 300,000 EACH ACCIDENT 35 30 UNINSURED MOTORISTS il: A Pvv!;voN"MtO 0011 PROPERTY DAMAGE UABILITY $3,500 MAXIMUM 7 COLLISION DEDUCTIBLE WAIVER 2 MEDICAL EXPENSE $ LEASEILOAN GAP COVERAGE �CAR CAR CAR REPAIR OR REPLACEMENT �CAR CAR CAR COST COVERAGE COMPREHENSIVE olouolmkCAR $ CAR2 $250 CAR $ 1 CAUFORNIA ASSESMENTS COWSION DEDUCTIBLE CAR $ CAR2 $500 CAR $ 20) CA FRAUD FEE 1.76 ROADSIDE ASSISTANCE PER OCCURRENCE CAR CAR CAR CIGA FEE RENTAL CAR BENEFIT 1$30 PER DAY 30 DAYS 15 INTERVENOR FEE �77 ENDORSEMENTS ATTALICHED TO TflE PGLIGY PREMIUMS PER CAR U-10 06/2016 U-44 U-45B 222 443 POLICY FEE TOTAL PREMIUM IMPORTANT INFORMATION EFFECTIVE 02/01/2018 The enclosed Auto Insurance Renewal Bill and the U251 IMPORTA14T NOTICE are part of this specify the amount of your premium, your payment options, in, Your automobile insurance expires and coverage ceases at this policy will become effective provided you on the Auto Insurance Renewal Bill. If you have on',,' the phone number provided above. .............. MAILED TO: KIMBERLY L WAKEFIELD 435 LOMITA ST POLICY NUMBER,- 0401 09 170043777 EL SEGUNDO, CA 90245-4054 MAiLINGDATE-. 01/0212018 IJ INSURED COPY WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job : $5 , 000 . 00 Sample Rate : 13 . 30% Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00% Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95) POLICYHOLDER COPY SC STATE P.O. BOX 8192, PLEASANTON, CA 94588 INSURANCEFUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 02-12-2018 GROUP: POLICY NUMBER: 9225322-2018 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 02-01-2019 02-01-2018/02-01-2019 CITY OF EL SEGUNDO SC 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. ."ezz-AeZ14�1 Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018-02-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO ENDORSEMENT #1951 - WAKEFIELD,KIMBERLY MGR-MEMBR - EXCLUDED. EMPLOYER LEAP SPORTS ACADEMY LLC DBA: SUPERTOTS SPORTS ACADEMY 435 LOMITA ST EL SEGUNDO CA 90245 [P1 V,HO] (REV.7-2014) PRINTED : 02-12-2018 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION STATE 9225322-18 COr�_ NEW SC FUND PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 1, 2018 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING FEBRUARY 1, 2019 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SUPERTOTS SPORTS ACADEMY 435 LOMITA ST EL SEGUNDO, CA 90245 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, SUPERTOTS SPORTS ACADEMY 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: FEBRUARY 7 , 2018 2570 Fwl�1R'dOR9�'Etl IEPRE aENI IVF. PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217