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PROOF OF INSURANCE (2019) CLOSED DATE IMMMDrrrM ACORD- CERTIFICATE OF LIABILITY INSURANCE p IF 111912018 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(ias)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, K&K INSURANCE GROUP,INC. CONTACT Cheryl Pettibone 1712 MAGNAVOX NAY E-Mail, 800-73rr7350 k,., I rC0 647-953-2673PO BOX 2338 FORT WAYNE IN 46801 ADORS 1:.. Che Petnbone andkl "._R.. .•... li.... .........-...-.. ....,......._-- PAME ryi, nsurance_com ^ INSURED -.___,.........- ..........,..m...INSURERS)AFFORDIN,G,COVERAGE................m.......,_..,,.,....,......................NAIC., ,.,.,.,.,.....,.,., MEMSEP NO: INSURER A: Nationwide Mutual Insurance Company 23757 EL SEGUNDO BABE RUTH LEAGUE INSURER C; Nationwide Life Insurance Company mm . ..... ...... IT DBA:EI Segundo Babe Ruth INSURE_ .,a............m_._................................. ...- �. ... ....... ... ... .._ 750 Sierra Street R D6' INSURER E EI Segundo.CA, 90245 ,-�..---..---..-..m...._._... g INSURER F: 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ...INSOADM .tl..ID —...ILIBIR ICY NUMBER fFF POLICY EXP L10.91TS ... 6NSR...,.....,. ...............................TYPE OF INSURANCE Iy50 SMlVO ....PDL..,.®......®.,..m,.._.....,...___....a,Id1,MNnY __LMWDDIYYYY) .....,,„.........�.� �I$2.000,000 L'TR A .,.X.. COMMERCIAL CLAIMS-MADE XM1 OCCUR 02!01!2018 02J0112018 EACH HEN:�ra�p�a?c+vl...—�.�... .�^.3���,....Y.. .. Y RPG-264825-00 12:01 AM 12:01 AM MED EXP(Any one person.) 5 5,000 GG I PERSONAL 8 ADV INJURY 52,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 ................ — _. .........I GG $2,000,000 OTHER: PROJECT OC PARTICIPANT LEGA LIABILITY —_ Sz.000,Doo AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 51,000,000 ANY AUTO BODILY INJURY(Per person) 'OWNFD' SCHEDULED 02!01!2018 0210112019 A AUTO'S ONLY AUTOS RPG-2a,1825-0012:01 AM 12:01 AM BODILY INJURY(Per accident).._ .�....._....... ^� ,�,"^, "HIRED .__. NON-OWNED FRoE`E"STI�IiMAGE x x AUTOS ONLY AUTOS ONLY I ER LIAR OCCUR EACH OCCURRENCE .., _...I UMBRELLA B _.._ ,., � ,._a..... ._... DED R ..LIAR"".."""."..'..CLAIMS-MADE � ..._—' AGGREGATE RETENTION WORKERS COMPENSATION .. .f ❑ .,E !yIIPEft 1OTHER AND EMPLOYERS'LIABILRY YSTATUTE ANY f ROTI'R'&E'P'OWP�A qTN@r`',XECUTIVE I EACH ACCIDENT OFrICERFM'EMBER EXCLUDED" �I N f A (Mandatary in NH) EL DISEASE—EA EMPLOYEE If VQ 9,destnbc under ......... DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT 02101/2018 02/0112019 Excess Medical $250.000 B PARTICIPANT ACCIDENT JXS-284626.00 12:01 AM 12:01 AM AD&D S 15,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED,BUT SOLELY WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED. Owner,manager or lessor of the premises where you conduct practices or games SEXUAL ABUSEIMOLESTATION: $1,000,000 PER OCCURRENCEI$2,D00,000 AGGREGATE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, City of EI Segundo AUTHORIZED REPRESENTATIVE 350 Main Street El Segundo, CA 90245 ACORD 25(2016103) ©5988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: RPG-284825-00 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE A IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON R ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE City of EI Segundo its officers,officials, employees,agents and volunteers 350 Main Street E! Segundo, CA 90245 RE: El Segundo Babe Ruth League Information required to complete this Scheduie, if not shown above,will be shown in the Declarations. A. Section II — 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 organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for"bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of Insurance shown in the Declarations; 2. In connection with your premises owned by or whichever is less. rented to you. However: This endorsement shall not increase the 1. The insurance afforded to such additions! applicable 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 0 insurance Services Office, Inc., 2012 Page 1 of 1 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 El 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 El Segundo is executed.My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# ( —V1 1 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 th a provisions o0hp agreement will automatically become void. Signature of Applicant .:: . :: ' •� ..,�^) Date ���7�/ ` v k Agreement for: �i� � I'' L Dated: Cl/N- _ .. Reviewed by: I 1