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PROOF OF INSURANCE (2018) CLOSED 189026 Coach Derek Inc Certificate Of Insurance Page(1 of 2) 6/4/2018 7:55:10 PM C CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 6/4/2018 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(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: PHONFAX E Wc� (PIRG No,Esq); (800)688-1'984 ,,,.Nojl 877-826-9067 EMAIL BIN Insurance Holdings,LLC ADDRESS: 30 N.LaSalle,25th Floor,Chicago, IL 60602 INSURERIS)AFFORDING COVERAGE NAIC# INSURER A: Scottsdale Insurance Company 41297 INSURED INSURER B: TBD Carrier 000000 Coach Derek Inc INSURER C: 2711 N.Sepulveda Blvd,Suite 211,Manhattan Beach,CA,90266 INSURER D: INSURER E: INSURER 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 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�i .INS .I)N$�DDL o POLICY NUMBER (MM DDyIYEYYY). (MIDDI'Y EXr'. gm7R TYPE OF INSURANCE ((MMI00/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ✓,,,i OCCUR AGE'10 RENtED ) 100000 DAIS PREMISES Ea occurrence $ „MED EXP(Any one person) $5.000 A Yes CPS2722571 10/10/2017 10/10/20161,000,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2.000,000 I PRO. POLICY�_____7 JECT LOC PRODUCTS-COMPIOP AGG ffi 2,000,000 OTHER Abuse Coverage Occ/Agg $ 25,000/25,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PIOPr:gTT"1"DAMAGE . .� ..., HIRED AUTOS AUTOS (Per accidet d) .,s ..... 0 UMBRELLA LIAB ✓ OCCUR EACH OCCURRENCE $ EXCESS LIAB ��CLAIMS-MADE AGGREGATE II,$, DED I I RETENTION$ SWORKERS COMPENSATION .. AND EMPLO ERS'L ABILIITY Y/N I PER U1 STATUTE, OI H ........ ...... . EL EACH Orn t B I MEIMER EXC UDED'ANY �EI fiOWu N/A daE L D SEASEC IDENT rEA EMPLOYEE It yyes,describe wnyden OES'C'RU311'ON OF OPERATIONS'balo w EL DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of EI Segundo,its officers,officials,employees,agents,and volunteers are named as additional insured with respects to general liability.This insurance is primary and non-contributory to any other insurance provided as respects general liability coverage.Should any of the above described policies be cancelled before the expiration date,the issuing insurer will endeavor to mail 30 days written notice(10 days notice if due to non-payment)to the certificate holder named below,but failure to do so shall impose no obligation or liability of any kind upon the insurer,its agents or representatives. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 189026 Coach Derek Inc Certificate of Insurance Page(2 of 2) 6/4/2018 7:55:10 PM AGENCY CUSTOMER ID: 189026 LOC#: C" " " ADDITIONAL REMARKS SCHEDULE PInsureonage 1 of 1 AGENCY NAMED INSURED Coach Derek Inc POLICY NUMBER 2711 N.Sepulveda Blvd,Suite 211 Manhattan Beach,CA 90266 CARRIER NAIC CODE UEFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 251 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE The City of EI Segundo,its officers,officials,employees,agents,and volunteers are named as additional insured with respects to general liability.This insurance is primary and non-contributory to any other insurance provided as respects general liability coverage.Should any of the above described policies be cancelled before the expiration date,the issuing insurer will endeavor to mail 30 days written notice(10 days notice if due to non-payment)to the certificate holder named below,but failure to do so shall impose no obligation or liability of any kind upon the insurer,its agents or representatives. ACORD 101 (2000101) Q 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF EL SEGU14DO 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 HUNDREDTHOUSAND DOLLARS ($100,000), IN' ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEYS FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: LJ 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 have and will maintain workers'compensation insurance as required by Labor Cade§3700 forthe 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# AI certify that, In the performance of the work set forth in the agreement with the City of El Segundo, I will not M toy 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 § 37 1 ust immediately comply with those."o sions or the greern 11t Wutomatically become void. Signature of App,!a, ate ant " D, Print Name Agreement for toad, %� (K(/- - A, Dated: Reviewed by. Ads!