PROOF OF INSURANCE (2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE
................ 01/09/18
RiCOUCER ...........a................
CERTIFICATE#: 4053601-2018-1 4 05 36
Keystone Risk Managers, LLC
1995 Point Township Drive
Northumberland,PA 17867 INSURERS AFFORDING COVERAGE:
A=TIChV\L NAMED INSUREU INSURER A: L�xiVon:Insurance Company
EL SEGUNDO ILL
INSURER 11: National Union Fire Insurance Company Lance Giroux Pa y of
714 Bungalow Drive (Non-Liability) Pittsburgh,PA
EL SEGUNDO,CA 9D245 INSURER C: AIG Specialty Insurance Company
COVERAGES............ J
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I"S$ED TO THE INSURED NAMED AB'OV'E.FOR THE POLICY PERIOD INDICATED NOTWITHSTANDIING
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 Or-SCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADVIL ,
LTR NMED TYPE OF INSURANCE -YNUMBER POILJCY EFFECTIVE POLICY EXPIRATION
I,NSRD, I � �� 1 1. , ,,, , I ,POL!C.......... DATE.. ..11{I M 11 WDDJYYYY I DATE(M MID Df yy LlMr S
GENERAL LIABILITY I g��H OCCURRENCE $1,000,000
011225822 0110112018 0110112019
• X X OCCURRENCE GEN ERAL AGGREGATE $2,000,000
X INCL PARTICIPANTS Property Damage Deductible:$250 PRODUCTSICOMP CPS
-r $1,000,000
AGGRE-ATE
Sexual Abuse
SEXUALABUSE OCCURRENCE $1,000,000
Sexual Abuse
AGGR15-GATE $2.000,000
E
..................
MEDICAL PAYMNTS Any OnL PersonII
'111111"mlol
• X DIRECTORS&OFFICERS 019130066 01/01/2018 01/0112019 EACHLOSS $1,000,000
AGGREGATE $1,000,000
C X
CYBER LIABILITY COVERAGE 018 254546 01/0112018 01/0112019 LIMIT OF LIABILITY 11 00,00 0 PER
CLAIMS MADE LEAGUE AGGREGATE
S&P SECURITY AND PRIVACY LIABILITY $100,000 PER LEAGUE SUBLIMIT OF LIABILITY RL-rROACnVE DATE CONTINUITY bA�
C I E $1,000 PER LEAGUE I R I ETENTION POLICYINCEPTON POLICYINCEPTION
REGULATORY ACTION SUBLI MIT OF $100,000 PER LEAGUE SUBUMIT OF LIABILITY
LI A 31 L I T Y $1,000 PER LEAGU E RETENTION
EM EVENT MANAG MENT INSURANCE I $1,000
PER LEAGUE SUBUMIT OF LIABILITY NOT APF-JCABLE POLICY INCEPTION
1,000 PER L E A GU E RETENTION
A X CRIME COVERAGE 01140 8 723 0 1/01/2018 0110V2019 EACH LOSS $35,000
I , , ... .......... ...
C ri me Deductible:$250 Propertyl$1,000 M oney AGGREGATE NONE
....... .. .........
As
B X SPORTS EXCESS AC SRG Gllister Policy: As in Master Policy
CIDENT 9105434 D1101/2018 010112019 Med.Max.$100,000 Excess
,, A - :IddIII I Deductible $50
'X"IN]DICATFS C0VFRAQEI[S)_agl,! �-APpITIONAL,NAMEp INEug In
ADDITIONAL INSURED
Who b an Insured(SECTION 11)of the General Urabifty pir&oy is amended to include as an insureiJ the person or rirgarzation Showy,in the schodule,but only with respect to
liahilrly afting out of the above named Little League's maintenance or use of ball fields,or other Prernises loaned,donated,or rented to that Utdo League by such person or
organizations and Subjed to this lotiovong arkAtional cxrluslons,
1.Structural alterations,new construction,maintenance,repair or demolition operations performed by or on behalf of the person or organization designated in the Schedule and/or
performed by the above named Little League;and
2. That part of the hall field or other premises not being used by the above named Little League.
NAME AND ADDRESS OF PERSON OR ORGAN[7-ATIDN:
City of El Segundo,Its Officers,Officials,Employees,Agents and Certified Volunteers
350 Main Street
El Segundo,CA 90245
INSURED CANCELLATION
SHOULD ANY OF THE ABOVE: DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
Little League Baseball Risk Purchasing Group,Inc. WITH THE POLICY PROVI, N .
539 U.S. RT.15 Highway
South Williamsport,PA 17702
AUTHORIZED 46PROSEWAIVE
ENDORSEMENT
THIS ENDORSEMENT EFFECTIVE: 1/01/2018 AT 12:01 AM
FORMS A PART OF POLICY NO.: 011225822
ISSUED TO: LITTLE LEAGUE BASEBALL RISK PURCHASING GROUP,INC.
BY: LEXINGTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY.
ADDITIONAL INSUREDS
This endorsement modifies insurance under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
In consideration of an additional premium of$N/A it is hereby agreed the following are added as
Additional Insureds.
Co-promoters
Sponsors
Landlords City of El Segundo, its officers,officials, employees, agents and volunteers
360 Main Street
El Segundo, CA 90245
Entertainers
All other terms and conditions remain unchanged. But only to the extent that liability results from
negligence of the Named Insured.
Authorized Representative
72984(4/99)
p'il`, it II I
M
EI Segundo Little League Board of Directors
To: City of EI Segundo Parks and Rec
Fr: Ted Lappe- President of EI Segundo Little League
RE: Auto Insurance
Date: 10/16/18
To Whom it May Concern;
EI Segundo Little League does not carry any Auto Insurance as we have no Vehicles that are owned or
Operated by the League.
Regards,
Ted Lappe
President ESLL
PO BOX 112
EI Segundo, CA 90245
CITY OF EL SEGUNDO
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 HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_)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 EI Segundo.
Policy No.
(_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance
of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier „ Policy Number Expiration Date
Name of ent Phone#
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
e ploy 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 th orkers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those proOs'ionsfs agreement will automatically become void.
Signature of Applicant t' Date 111//7
Agreement for:
Dated:
Reviewed by:
P"P, T-, LU� ��