PROOF OF INSURANCE (2019) CLOSED ACCW" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYY)
N 8//12018
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).
ACT
PRODUCER WIV'lis insurance Services of Georgia, Inc. NAME: Holly Veach
Concourse Corporate Center Five PHONE PC 'X372 2n76 E 7961 FAX
18th Floor (A ,Nob Exit); (��a, ) (wc„No,) 310-525-1155
Atlanta, GA 30328 EMAIL
nppREss: ecerts a�ayso org
INSURER(S)AFFORDING COVERAGE NAIC#
www ayso.org INSURERA: Everest National Insurance Company 10120
INSURED INSURER B
American Youth Soccer Organization
INSURER C.
,YSO Region OA092
19750 S. Vermont Avenue, Suite 200 INSURER
Torrance CA 90250 INSURER
INSURER F:
COVERAGES CERTIFICATE NUMBER: 43460032 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 SUBR POLICY EFF POLICY EXP LIMITS
LTR 1N�j.1 wVD POLICY NUMBER IMMIDD/VYYYI 1MM/OD/YYYVI
A / COMMERCIAL GENERAL LIABILITY ✓ S18ML00321-181 7/1/2018 7/'1/2019 EACH OCCURRENCE $1,000,,000
DAMAGE'1'0 HEN FE D
CLAIMS-MADE ,/ OCCUR P,REd,rl,0'SE?a';"El Oc(�i,arrt+r�r:+M!,, S 2,.000,000
JParticipant&Legal Liability MED EXP(Any one person) $10,000"
V A&M$1 M OCC/$2 agg PERSONAL&ADV INJURY $1,000,000
GEEN'L AGGREGATE L IMIT APPLIES PER GENERAL AGGREGATE $3,000,000
POLICY JECT I LOC PRODUCTS-COMP/OPAGG 53,000,000
Per,Rection('25M Pol Ao4) $
AUTOMOBILE LIABILITY COMBINED$Oh GL'E Llk l I $
I&I rr,.nen;)
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE 5
AUTOS ONLY AUTOS ONLY (Per ar.r,!dent,),
S
A �/ UMBRELLALIAB ✓ OCCUR S18EX00267-181 7/1/2018 7/1/2019 EACH OCCURRENCE 54,000„000
EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000'
DFn ✓ RETENTION$t) $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Gro IATU'I LE Eft
ANYPROPRIETOR/PARTNER/EXECUTIVE Y� N/A E L EACH ACCIDENT $
OFFICE R/MEMBER EXCLUDED?
(Mandatory in NH) EE L DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E L, DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
'Med Pay applies only to spectators at an AYSO Event,
Certificate Holder is an Additional Insured as respects AYSO sanctioned events only as per the attached endorsement,
General Aggregate Limit Applies on a per Region basis
Hired/Non-Owned Auto Liability only apply to American Youth Soccer Organization National Board of Directors(NBOD),National Office Directors,and
approved listed volunteers conducting business and/or assisting with AYSO sanctioned events.
CERTIFICATE HOLDER CANCELLATION
RGN 0092
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
The City of EI Segundo, Its officer's, officials THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
employees, agent, and volunteers ACCORDANCE WITH THE POLICY PROVISIONS.
350 Maln St
EI Segundo CA 90245
AUTHORIZED REPRESENTATIVE
Britt Pyle
Q 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
03.750032 I 201Ei-2479 Master Cerrlfic to I Aegir,n OG92 1 0/1/2018 3:241:31 YM (PUT) I lege 1 of 2
Tnis terrific--,te tarsals unci supe—e_des ALL, prey 2sly f sur.ri c Lx ficaces
S18M L00321-181 8/1/2018
American Youth Soccer Organization
RGN 0092
COMMERCIAL GENERAL LIABILITY
ECG 20 600 05 09
THIS ENDORSEMENT CHANGES THE COVERAGE PART. PLEASE READ IT
CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS WHEN
REQUIRED IN A WRITTEN AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II — Who Is An Insured is amended to C. The Limits of Insurance afforded to an additional
include as an additional insured any person or or- insured shall be the lesser of the following:
ganization with whom you have a written agree- 1. The Limits of Insurance required by the written
ment that such person or organization be added as agreement between the parties;or
an additional insured on your Coverage Part_ Such
person or organization is an additional insured only 2. The Limits of Insurance provided by this Cov-
with respect to liability for "bodily injury", "property erage Part.
damage" or "personal and advertising injury" but D. With respect to the insurance afforded to an addi-
only to the extent caused, in whole or in part, by: tional insured, this insurance does not apply to
1. Your acts or omissions; or "bodily injury', "property damage" or"personal and
advertising injury" arising out of any act or omis-
2. The acts or omissions of those acting on your sion of an additional insured or any of its employ-
behalf, ees.
in the perFormance of your operations for an addi-
tional insured.
B. The insurance afforded to an additional insured
shall only include the insurance required by the
terms of the written agreement and shall not be
broader than the coverage provided within the
terms of the Coverage Part.
The City of EI Segundo, its officers, officials
employees„ agents, and volunteers
350 Main St
EI Segundo CA 90245
ECG 20 600 05 09 Copyright,Everest Reinsurance Company 2009 Page 1 of 1 ❑
Includes copyrighted material of Insurance Services Office, Inc.,used
with its permission.
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CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE ORII~ ERS'CO PE SATION COVERAGE
IS UNLAWFUL L AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,10010).
IN ADDITION TO THE COST OF COMPENSATION,PENSATION, DA AGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST,AND ATTORNEY'S FEES.
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Policy No.
U I haft-and will mair"in workers°compensation insurance as regwted by Labor Code 3700 for ft pedormance
of the timrk for which the agreerree t with the City of F-J Sogundo is executed. My workers'ouvVensation insurance
sailer and pu6[y rKimb m we.
Carrico Po" Numbcx Expiration Da'fc
Name of Agent Phcne fe
I cavity that. m Ittia perforrnanoe of the iiVivuft '.'pmt forth in the agreement rrM the City of EI Segundo. I willi not
c nploy any pe on in any marries so as to spjeo to the workers' compensation laws of Calihxnia,and
a9+ac that, if I should become su „ eadcoLabor Code
'3700 EIW
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