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PROOF OF INSURANCE (2018) CLOSED ACV CERTIFICATE OF LIABILITY INSURANCE DATE(04/2018 ��,. I 05/04/2018 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 INSURERS), 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 1 CONTACT NAME: Mass Merchandlsin0 Group, ry PHONE FAX ...., Fort Wauneav 46804 Inc. E-MAIL satl: n o@ portsi8nsurance-kk.com�AYc Na): 1-260-459-5105 1712 Magnavox Way D.M,A)L Y CUSTOMER to: INSURER(S)AFFORDING COVERAGE NAIC# l INSURED 2000953742 CP#7101 INSURER A: Nationwide Mutual Insurance Company 23787 South Bay Youth Sports INSURER B: G DBA:Go Loong Sports INSURER Cs 531 Main Street,#321 INSURER D: EI Segundo,CA 90245 INSURER E: n A Member of the Sports,Leisure&Entertainment RPG 'INSURER F: COVERAGES CERTIFICATE NUMBER:2000359630 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 SUER POLICY NUMBER POLICY EFFPOLICY EXP LIMITS LTR INSD WVD (MNVDD/YYYV) (MM/DD/YYVYI .._.... .........._.._. ............ ......._...,....,_,.,.,.,.,.,.,..,..,.,.,.,.,.................... A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006055100 12/01/17 12/01/18 EACH OCCURRENCE $2,000,000 CLAIMS•MADE II X OCCUR 12:01 AM 12:01 AM DAMAGE TO SEWED FX J PREMISES(Ea Occurrence) $1,000,000 ' MED EXP(Any one person) $5,000 V PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $5,000,000 POLICY ❑PROJECT❑LOC PRODUCTS–COMP/OP AGG I $2,000,000 OTHER: PROFESSIONAL LIABILITY I $2,000,000 LEGAL LIAB TO PARTICIPANTS $2,000,000 A AUTOMOBILE LIABILITY 6BRPG000000605510012/01/17 12/01/18 ao M81NEb SINGLEIMIT(La $2,000,000 r,i} 12:01 AM 12:01 AM cidenll ANY AUTO BODILY INJURY(Per person) OWNEDSCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) X Not provided while in Hawaii —� UMBRIELLA OCCUR EACH OCCURRENCE LIAB EXCESS LIAB CLAIMS-MADE AGGREGATE DED n RETENTION WORKERS COMPENSATION N/A �PERSTATUTEuOTHER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/ Y/N E L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH) I E L.DISEASE–EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE–POLICY LIMIT 4 MEDICAL PAYMENTS FOR PARTICIPANTS 12/01/17 12/01/18 PRIMARY MEDICAL 66RPG0000006055100 12:01 AM 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 161,Additional Remarks Schedule,may be attached if more space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Sport(s):Football(Flag&Touch)Age(s):12 and under, 13-15 The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured. This certificate voids and replaces certificate#W01132197 Limits referenced above effective 4/26/18 CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 350 Main Street EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH EI Segundo,CA 90245 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE //, � 01988-2015 ACORD CORPORATION. All rights reserved. Coverage is only extended to U.S.events and activities. "NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPGO000006055100 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Or ani ation(s) City of EI Segundo 350 Main Street EI Segundo,CA 90245 Ref:South Bay Youth Sports DBA:Go Loong Sports Ref:CP#7101 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. i A. Section 11 — 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 M—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 our remises owned by or 2. Available under the applicable Limits of 2. In connection with Y P insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the applicable 1. The insurance afforded to such additional 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 r 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: U I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# C$) 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 a subject to the workers' compensation provisions of Labor Code § 3700 1 must g y py p automatically become void. Signature of Applicant coh thos rovisions or e agreement will g ..�..�, .. .... . ..... Date ! Ag reement for: "k�m"IA, ell Dated: Reviewed by: r 1 0113TH 80 � f$Pee* 531 Main Street,#321, EI Segundo,CA 90245 www.southbavvouthsoorts.org To Whom It May Concern. CERTIFICATION OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE This letter has been written to inform you that South Bay"Youth Spats does not carry Workers Compensation Insurance by State of California as we do not have any employees. All workers for our agency are either volunteers or consultants. Business Automobile Insurance South Bav Youth Sports do not own or lease a Business Automobile. Licensee: Joe Wang, President