PROOF OF INSURANCE (2019) CLOSED A4C<>RL Y DATE IMMIODfYYYYR
CERTIFICATE OF LIABILITY INSURANCE I 01112i2018
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND,CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEN.THIS
CERTIFICATE DOES'N'OT A'FFI!RMATIVELY 0'R NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE A'FF'ORDED BY THE POLICIES
BELOW. THIS'CERTIFICATE OF INSURANCE DOES NOT CONSTTFU'TE A CONTRACT BETWEEN THE ISSUING INSURERIS),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE.CERTIFICATE HOLDER.
IMPORTANT:If th'e certificate holder is an ADDITIONAL INSURED,the pollcy(ies,)must be endDrsed, If SUBROGATION IS WAIVED,subject
to the terms and conditions of the policy,certain policies may,require an'endor'se'me'eL A statement on thli9 certificate does not con'fe'r
rights to the certificate holder in:lieu of such e'ndome'mentls).
PRODUCER CONTACT
RPS Bollinger NAME:
150 JFK PARKWAY.4TH FLOOR PMORE FAX
PO Box 390 IAS„,No,Ertl.800.446-5311
(AJC,Ito 973-9214474
SHORT HILLS.NJ 07078 E•NAIL
PHONE:1.800-446-5311 FAX:973-921-.474
ADDfEfi:
INSUR''E'RrSI AFFORDING COVERAGE MAIC S
INSURER A:Markel Insurance Company 3a970
INSURED INSURERS:
USA.Softball and Members of USA Softball of SoCal Indiv Reg INSURER C:
Program
Phil Gutierrez INfURERD:
PO Box 5028 1NSURERE:
Oceanside,CA 92052 INSURERF:
COVERAGES POLICY CHANGE NUMBER,IR0156206 REVISION NUMBER:
THIS IS TO'CERTO'FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAIAED ASOVE FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REQU'IREMEN'T,TERN OR CONDITION OF ANY CONTRACT OR'OTHER DOCUMENT'WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED
OR MAY PERTAIN,THE INSURANCE'AFFORDED 9Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUS'ION'S AND CONDITIONS OF SUCH
POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MIR PE OF INSURANCE AOOL S” POLICY NUMBER I I LIMBS
LTR IafR WVO r"wooIYYYYI` Pwpoff]�
!
GENERAL IIABILITY X OCCURRENCE _
A x CO'Ia'IT,ERCIAL GENERAL LIABILITY DAInAGE To RENTED
CLAV'MS tWDE X OCCUR
360a2Al 30069 111:2018 1?1,2D19 IPRENUMSfEaoxunwm) $1,
D t ' S10,aMY•
X Porti
dpants Liab *Non-participants only aAIN RM RY S2:
GEi.EAAI.,Ac3GREGATE 35;
iEN'"L AGGREGATE LIMITAPPLIES PER: I
L'cal Abta &Ntol nation Liab pv vxurmwv S10r%1OW PRODUCTS-COWOVAGG 32:
POLICY PRO X LOG amxaaIL1IVNcr34tl"olastati'm 4S , tmlimit:$2.0W,000 I S
AUTONIOBILE LIABIL�' CONER&D SNGLE MIT S
ANY AUTO v rrN I $
ALL OWNED SCHEDULED v f S
AUTOS AUTOS PROPERTYDAMAGE
HIRED AUTOS NON-OWNED 1 r $
AUTOS
$
UMBRELLALYIBOCCUR EACH OCCURRENCE
EXCESS LIAR tXwn>S- AGGREGATE
_ $
I DED FIRETENTION$
YIIORICERSCO'UPENSATION 1MCSTATi1 I -
AND EI4MPLOYERS'LIA01L'rTY $
ANYPR0PRETORPA;9'!'NMeXEr',JT'HME YIN
OFFCERrI NIM eR EXCLUDED? NIA EL. $
(Mandatory In NIH) F11ry� rus er
.dsacW DESCRIPTION OF �Ea, EA ... 3
OPERATIONS bskr& I E.L.'03F..'A, .POLICY LfiffI
OTHER i
dE iCC'RIPTION OF OPERATIONS I LOCATIONS i VEHIC.ES(Atiach AC6k6'i6i Add
diona Remarks Schedule,it mole space is required)
COVERAGE UNDER THIS POLICY SWILL APPLY TO LWBIL17Y OF THE INSURED ARISING OUT OF THE ADMINISTRATION.PLAYOR PRACTICE OF AMATEUR'SOFrBALLrBAS'EBALL,
BUT ONLY FOR INCIDENTS INVOLVING BODILY INJURY,PERSONAL INJURY OR PROPERTY DALE. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED.THIS
CERTIFICATE IS ISSUED ON BEHALF OF:EL SEGUNDO GIRLS SOFTBALL
CERTI'FIC'ATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED
BEFORE'THE EXPIRATION DATE THEREOF,NOTICE WILL HE DEL'IVER'ED I'll
The City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS,
350 Nfain st_
EI Segundo,CA'90245
AUTHORIZED REPRESENTATIVE
�
41 1 983-20 10 ACORO CORP"ORATIO'N, Afirighbreavved.
A'CORD 25{2010105} Thea ACOR'D no"and logo are'reghteaed'murlta of A,C.+ORD
TIES ENDORSE CHANGES THE POLICY.PLEASE READ'IT CAREFULLY
ADDITIONAL INSURED -DESIGNATED PERSON OR ORGANIZATION FOR
USA SOFTBALL ACTIMIES
This endorsement modifies insurance provided under the following:
CORMCM GENEM LLMLM CDAMLIkGE FORM
With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by the endorsement.
Name efingurid
USA Softhan aid Membars of USASoftbaU of SoC;sl'h%4,v FaZ Progrzai
The City of M Segundo
Polky Numbe Policy Aeiod Endom-mrowi Orliva Date
3'602AM30�069 I MaOIS-1)1./2019 As shown an the stwlmd CartdKjm aflusumm
IMYA By I Authoiiza4 RWnsmWM
&LkML INSURANCE COAMM
Mwzbove4idx=cion is rNuhad only vbm thisi is le%. er,N policy is i5msd,
SCHEDULE
Name of Person or Organization-
As Show on the Attached Certiricate of Insuramee
AThe following is added to Section TI-NNIHOISAN INSURED:
The person or organization shown in the above SCHEDULE but only with respect to liability arising out of the organization,
promotion,administration and conduct of amateur softball activities,including games,practices,tournaments,and fwad-raising
activities,under the rules of the USA Softball,provided:
a. That if the person or organization is desi ted as a Team,the person or organization so desip
Pat pated shall be deemed to
include team members,managers,coaches,assistants,batboys,registered scorekeepers,sponsors,any odier indi%idual
participating,in the official functions of the team,and if soindicated,a Field Owner,but only for li'abil'ity ansing out of the
designated Team's amateur softball activities:covered under this policy;
b. That if the person or organization is designated as a League,theinterest of the League shall not be included unless all teams
in the,League purchase this insurance,When the interest of the League is so included,the person or organization designated
as a League shall be deemed to include all teams in the league and team members,managers,coaches,assistants,batboys,
registered scorekeepers,sponsors,any other individual participating in the official functions of the League or of any such
teams,and if so indicated,a Field Owner,but only for liability arising out:of the designated League's amateur softball
activities covered under this policy,
.All other terms and conditions of this policy remain unchanged,
1/14
50
NO 7� CA rr � k),,5 vkra,
ayb
0X44 Ol � � f
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 Agent Phone#
(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 1 must
immediately comply with those provisioy sµrti'f the agreement will automatically become void,
" .._
Signature of applicant Date
Agreement for: ;
Dated:
Reviewed by:
1