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PROOF OF INSURANCE (2019) CLOSED
DATE WNVit':If7W0"Y0 i CERTIFICATE OF LIABILITY INSURANCE 1!10/2018 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 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 CONTACT NAME: Bollinger,Inc. PHONNo Fxt1 800-446-5311 I(AIS Np,. 973-921-2876 150 JFK Parkway E-MAIL PO Box 390 ADDRESS: Short Hills,NJ 07078-5000 PRODUCER CUa Q""T MER 1Cb d: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Markel Insurance Company 38970 US Lacrosse,Inc. INSURER B: 2 Loveton Circle INSURER C: Sparks,MD 21210 INSURER D: Re: EI Segundo Lacrosse Assoc, INSURER E: pp INSURER Fr I� COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBRPOLICY NUMBER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVo g502AH221369 I M/DDIY 8 1_ (MWO I I FAGI i OCCURRENCE LIMITS GENERAL LIABILITY IIdI�dI::NCE � $'1,000,000 A X (.-LYItnIVII.Ict..lAl �INr12rtLIlABILIrY X .��w, ?E,,d,RE,R1T"ELI $300,000 Cl AIMS MADI. Fx I OCCUR MED EXP(Any one person) $5,000 X Incl,Participants I PERSONAL&ADV INJURY ' $1,000,000 X Excl Abuse Liab I GENERAL AGGREGATE $5,000,000 I ° AGCREGLNITAPPLIEadPRODUCTS-COMP/OPAGG $2,000,OOOPO � � OE �LOC U CT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHFF)UI I:I1 AUTOS ALL T'OS 1301}II Y INJURY(Per�acc:irterrll .�. HIRED AUTOS NON PROPERTY DAMAGE AU I OS (Per accident) A EXCESS LIAB CLAIMS MADE X AG OCCURRENCE $1,000,000 X UMBRELLA LIAB NOCCUR 4602AH221370 01/01/18 01/01/19 AGGREGATE $1,000,000� _ DED RETENTION S WORKER'S COMPENSATION Vuc S rA'IIJ I N�OTHER AND EMPLOYERS'LIABILITY Y/N v MTF R i ANY PROPRIETOR/PARTNER/EXECUTIVE 0 NIA E L EACH ACCIDENT OFFICER/MEMBER EXCLUDED? Mandatory in NH) I EL DISEASE-EA EMPLOYEE fI yes describer under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT A Accident Medical 4102AH025220 01/01/18 I 01/01/19 Acc Limit $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Coverage under the above policies is provided to the sponsor and participants of Event(s)to be held. Coverage applies only to the activities relating to this specific event.Certificate Holder is named as an Additional Insured, Certificate is issued on behalf of EI Segundo Lacrosse Assoc.. .................-........... ............. _. CERTIFICATE HOLDER CANCELLATION The City of EI Segundo,it's elected and appointed 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. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 8502AH221369 COMMERCIAL GENERAL LIABILITY U.S. Lacrosse, Inc. Policy Dates: 01/01/18-01/01/19 CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises(Part Leased to You): Athletic Facility 2. Name of Person or Organization (Additional Insured): The City of EI Segundo, it's elected and appointed officials, officers,agents and employees 350 Main Street EI Segundo,CA 90245 0000 Issued on behalf of: EI Segundo Lacrosse Assoc, 3 Additional Premium: NIL (If no entry appears above,the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS INSURED(Section II)is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1 Any"occurence"which takes place after you cease to be a tenant in that premises. 2 Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 azIdow 0 /Q 5 ":�)/o x`017 S- CITY OF EL SEGUNDO %tiARNI G: FAILURE TO SECURE WORKE & COMPENSATION COVO4LGE IS UNLA ,11FUL 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 § 3705, INTEREST, AND ATTORNEY'S FEES. 1 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 wor'lcers'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 LaborCode§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 Dumber Expiration Date Name of Agent Phone# (-W'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 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Replicant Date Vr e- f '70 i Agreement for: Dated: ! G" Reviewed by, �.., a