PROOF OF INSURANCE (2018) CLOSED At )R1,11'
• CERTIFICATE OF LIABILITY INSURANCE 10/24/2017
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EJ Segundo, CA a,A02,451
CERTIFICATE NUMBER
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C CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN
El Segundo Inline Hockey Association ACCORDANCE WITH THE POLICY PROVISIONS
PO Box 3061
El Segundo, CA 90245
(c)1988-2010 ACORD CORPORATION All rights reserved
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COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ ITCAREFULLY
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZATION
Insured: El Segundo Inline Hockey Association
Policy Number: SRPGP-101-0717 Policy EFF: 11/28/2017 1::.'Iolucy EXF1- '1112812018
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
...........
Name Of Additional Insured Person(s) Or Organization(s)
The City of El Segundo
350 Main Street
El Segundo,CA 90245
Information required to complete this Schedule, if not shown above will be shown in the Declarations
Section 11 - WHO IS AN INSURED is amended to include as an insured the person(s) or organization(s) shown in the
Schedule, but only with respect to liability for"bodily injury', "property damage" or"personal and advertising injury" used,
in whole or in part, by your acts or omissions of the acts or omissions of those acting on your behalf-.
A. In the performance of your ongoing operations-, or
B. In connection with your premises owned by or rented to you
El Segundo ire Hockey Association
Auto Insurance
11-6-17
To Whom It May Concern,
The EI Segundo Inline Hockey Association does not have auto insurance as part of our organization.
Regards,
Jeff Tiddens
ESIHA Board President
Page 1 of 1
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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 forthe 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 Agent Phone#
(X ) I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
employ 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 § 3700 i must
immediately comply with those provisions or the agreement will automatically become void.
Signature of Applicant Date 10-30-17
Agreement for: el Segundo Inline Hockey Association '� 1 NA w�
Dated:
Reviewed by: ,
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