PROOF OF INSURANCE (2020) CLOSED ,4coRn CERTIFICATE OF LIABILITY INSURANCE01110
DAT01110019 olnorol9
THIS CERTIFICATE I'S ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT'S UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND„EXTEND OR ALTER THE COVERAGE AF'F'ORDED 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 pollcy(ies)Inllust 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 I CONTACT
E.
BOLLINGER,InraAN
c.
Ptr'DNIE F+,X
100 JFK PARIKWAY,4TH FLOOR fNC. Bdl: &5311
PO Box 390 4A4'C,f4'o.1:973-921-9474
SHORT HILLS.,NJ 07073 ADD E=
PHONE:1-800-446-5S1 1 FAX.973-921-8474 I I'NSURERISI AFFORDING COVERAGE NAIC A
VuNSu A:Markel In,5urance Company 970
INSURED I nISURERB
US'Lacrosse,Inc. rerasu c
2 Loveton Citcle
Sparks.7VM 21152 1IMM.aRER f4:
Re:E,'I Se'gr ndo Lacrosse Assoc 1q01SU RE:
II ar450F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSI.IED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACT OR OTHER COCIUMENT WITH RESPECT TO WHICH THIS CERTIFICATE RAY BE ISSUED
OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUEUECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIUS
11145R TYPE OF INSURANCE ADDL SUSR POLICY NUMBER IJr-Y EFT PM.IDI..aC."fExp I LIMITS
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CLAIMS DE OCCUR 8502A 1369 11'1 1 01101 20 V7RFaN g5 iea _pFrr�r S1N7, 0
&uclual Atari. e A Mok-slatttrrc�I...iatr e? of r.n-iiia .'$'t1":,;1,""A0�
5-h L AGGREGATE LIMIT APPLIES PER. P:ENERCTS C01GATE ACm Sd•fa r tblk:t
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POLICY PRO- Kr LOC 1pg!ry Q
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AUTOMOBILE LIABILITY DOlieNZOSir�&F...I..KAT Ea Y1x1,,0-b'9; S
ANY AUTO
53DE Y IWURYIFe pa:raw!
ALLUWNED SCHEDULED 5001Lr p•„.il..,R,m"yWr:m)^6(:X!wln; S
®AUTOS AUTOS ROPErTYDAVAO. S
HIRED.AUTOS NON-OWNED Gr p '
AUTOS S
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UMBRELLA LIAB NX OCCUR x EAC.iOCCl.,:RrCEN;E
X EXCESS LIAB C4A14P r 4602AH22137B 011011"2019 0110112020' Y A3oFEGATE 5Owow
I
DEDRETENTION S
WORKERS C PEN SATIO Y/N N 1 p T S
ADE EMPLOYELIABIL AwsrAr�- R
ANY P% RE 0VPARTr ft.£XEC'JT Z Ore.Y t.IM75
O=F) r0AFV REXC1L 71a:T EAs nrr
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(Mandatory in H) S
Cy r _ r CRIPTON OF p,Ei! WU°EA- -GA Eu,w7r!UyEE ..�.._..�.._..�.......
CPERATiONS Derr» p E u.Ga�•;.,'�":.A•'r.::, rrDL l;:Y POI417 S II
A Accident Medical 4102AH025220 01101»2019 0110112020 A. dent Limit:5100,000
Catastrophic Ace 4102AH3050I82 01101120'19 0110'1!2020 Catastrophic Limit:S1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHIC_ES(Attach ACORD 101,Addition,Remarks Schedule,if more space is required)
Coverage applies only to teamslleagues comprised of 100%US Lacrosse member participants during scheduled&supervised lacrosse
activites.Certificate Holder is named"Additional Insured”with respect to EI Segundo Lacrosse Assoc.
CERTIFICATE HOLDER CANCELLATK)N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE(EXPIRATION DATE THEREOF,NOTICE WILL BE.DELIVERED IN
The Citi of'EI„aeurado,its officers,officials,efrlplo ee ,agents,and BEFORE
WITH THE POLICY PROVISIONS.
volunteers
350 R4ain Street
El Sgwido-CA 94215
AUTHORIZED REPRESENTATIVE
@19BB-27010ACORDCORPORATION. All rights reserved
AC'::XIf?If.:',25 12010., 5) The ACORD name and logo are registered mazis of.ACORD
POLICY NUMBER: 8502AH221369 COMMERCIAL GENERAL LIABILITY
U S Lacrosse, Inc
Policy Dates: 01/01/19-01/01/20 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,its officers,officials,
employees,agents and volunteers
350 Main Street
EI Segundo,CA 90245
Issued on behalf of:
EI Segundo Lacrosse Association Events to take place January 10,2019-January 01,2020,
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
Ya�T4
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GffY OFE-L SEGUNDO
�'!ORKERSI COMPENSATION DECLAF-,:.I!,.TiON
......................11.1.11........... ...........
1`_,'ARNING: FAILURE TO SECURE V,,jORKERWCOMPENSATION COVEIVWE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (WO,000),
IN ADDITtON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S EES®
I affirm under penalty of periury under the laws of California one of the following declarations:
I have and will maintain a certificate of consent of self-insure for workers'compensations, issued by the Director
1 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§3700forthe 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
i Name of Agent Phone#
(_011 certify that, in the perfbnnance of the work set forth in the agreement with the City of El Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, 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 Applicant ;a Date
n hyl\J24 4"�
Agreement for:.O_ 111,(kv L,6, o
2
Dated:
_)14
Reviewed by: