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PROOF OF INSURANCE (2018 - 2019) CLOSED 8 I DATE(MMIDD/YYYY( A WE` CERTIFICATE OF LIABILITY INSURANCE III 09/06/2018 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 g such endorsement(s). PRODUCERurtrficate does not confer rights to the certificate holder In lieu o s CONTACT „ Lockton Insurance Brokers, LLC-Encino ,NAME 16633 Ventura Blvd., Ste. 1300 IA1C,No, ExI}: (818) 836-5800 ggpC,,Noo;(8181 721-5800 EMAIL ADDRESS. Encino CA 91436 INSURER(S)AFFORDING COVERAGE NA,gC# INSURER A:State Compensation Fund of CA 35076 INSURED INSURER B:Nationwide Mutual Insurance Comp 23787 Culver City Swim Club, Inc. INSURERC: 15010 Doty Avenue INSURER 0: Hawthorne CA 90250 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 8565 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 iN SR IS POLICY EFF POLICY EXP TYPE OF INSURANCE NSID LTR INSO WV0VC1 POLICY NUMBER !MMIDDM'VVI—IMMIDD/YYVVI LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS MAIN � '�, OCY:LR y 6BRPG0000006430100 08/05/2018' 08/05/2019 Pl"a,V'a9,4SrX�II,kN'1'lal'yS 1,000,000 „ � r RE^x'0wi��Sv"L'�p�^„4DrrfJRe�,�6+,Y MED EXP(Any one person) Sf 5,000 PERSONAL&ADV INJURY S 1,000,000 - G,Lrq'iPd'JGIzF(w,—I u.,,oiI rs I'L R CLIVI"kA AGGRI:(:YA(1.- „ S 5,000,000 (M1"o Loc PRODUCTS-COMP/OPAGG S 1,000,000 07 HER S AUTOMOBILE LIABILITY F;0M8irJFQ S69V kk 0(0117 S 1,000,000 B ANY AU"ro 6BRPG0000006430100 08/05/2018 08/05/2019 19OIDII Y INANY(I>ur person) S OWNLI? SCHEDULED "901711 Y INJURYIlo(actaden1 $ At 1.1.1:3(1 01`4I..Y AUTOS ( ) I!.D NON-OEPR' } ROafn'1.'k, M1MAGE SXrX ONLY AUTOSS UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION S S WORKCOMPENSATIONc PER OTH- A AN EMPLER' ABILI I.IIVtm ❑ 9220982-2017 11/07/2017 1107 2018IXI ISATI,I,t:'.t::ll?I.:IVI FR S 1,000,000 AND EMPLOY" YIN / / ATR.7F. , •i-0 Fk IE'"u'I)'i AR'd''i" +MlMEI ''SDE NIA ., IMandalM In N'yl E L DISEASE-EA EMPLOYEEI S 1,000,000 It yp: do5cribu Iaoder )ESCH11"710IV 0 01-`FHA'I"KIM;Lehi 1I. n" si:ACI: POLICY LIMIT S 1,000,000 i B D & 0 6BDN00000006369600 08/05/201808/05/2019 Directors and 1,000,000 Officers Per Claim " B D & 0 6BDN00000006369600 08/05/2018108/05/2019 Directors and S 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 ACCORDANCE WITH THE POLICY PROVISIONS. City of E1 Segundo 350 Main Street AUTHORIZED REPRESENTATIVE E1 Segundo CA 90245 J ©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: 6BRPG0000006430100 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 St. EI Segundo, CA 90245 Re: Culver City Swim Club, Inc. DBA: Alpha Aquatics Cp#3054 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. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: 1. The insurance afforded to such additional This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by 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 04 13 ©Insurance Services Office, Inc.,2012 Page 1 of 1 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION _ 9220982-17 NEW SC ■ PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 9, 2018 AT 12 . 01 A.M. AND EXPIRING NOVEMBER 7 , 2018 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE 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, 21018 2570 AUTHORIZED REPRESENT IVC PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217