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PROOF OF INSURANCE (2019) CLOSED DATE(MMIDD/YYYY) ACC>R" CERTIFICATE OF LIABILITY INSURANCE ih. " 1 7/17/2018 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; RPS Bollinger PHONE FAX 150 JFK Parkway tAVc„No,Exl); 800-446-5311 (Arc,NoN;973 921-2876 4th Floor ADORCSS: sportservice@rps''ins.com Short Hills NJ 07078 INSURER(S)AFFORDING COVERAGE NAIC0 INSURER A:'Markel Insurance Company 38970 INSURED INSURER B:Markel Insurance Company 38970 US Youth Volleyball League 2771 Plaza Del Amo,#808 INSURER c Torrance CA 90503 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1368709235 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 ILTR' N4R SWVD, POLICY NUMBER IMOLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE DIYYYY) (MMIODIYYYY) A GENERAL LIABILITY Y 3602AH028574 8/1/2018 6/1/2019 EACH OCCURRENCE S 1.900,M)o X COMMERCIAL GENERAL LIABILITY 'RI,IASL,'~ I I"�Ip;cu Tu AMAf',f” YN'l . ,,(l:p,crPr.urrPnGr.:1 $100,00D CLAIMS-MADE X OCCUR MED EXP(Anv one person) $f000 PERSONAL&ADV INJURY., X Ind Participant F'E RY $1.I:100,0017 GENERAL AGGREGATE $3 W0,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ O. POLICY Q-7 X LOC Sexual Abuse/Mol $1mil/S2mil A AUTOMOBILE LIABILITY 3602AH028574 8/1/2018 6/1/2019 COMBINED SINGLE LdWT' tEaacc,den,i ,$I,LOQ,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS XX NON-OWNED PROPERTYDAMAGE .$ HlREDAUTOS „ AUTOS (Peraccident), S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETE14TION S $ WORKERS COMPENSATION WC:S)['A'I LI C)I 11 AND EMPLOYERS'LIABILITY YIN 1 4.)I-?Y LII111 T$: L;iq ., rY ) E L EACH ACCIDENT S ANY PR PR OFFICER/MEMBER EXCLUDED? NIA (Mandato m NH S E L DISEASE-EA EMPLOYEE, If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S B Accident Insurance 4102AH028573 811/2018 811/2019 Med Max S25,001) Full Excess Ded: $100 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The certificate holder is named as an additional insured under the liability policy. Coverage is provided for sponsored/supervised activities of the named insured. Group Code:3602AH028574 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. EI Segundo Recreation and Parks Dept 401 Sheldon Street AU7HRIZEDREPRESENT'ATIVE EI Segundo CA 90245 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:3602AH028574 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: EI Segundo Recreation and Parks Dept 401 Sheldon Street EI Segundo CA 90245 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 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: 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, U 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# ( ) 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 Applicant 4U.W, Date 11/21/2017 Agreement for: 2I A Dated: Reviewed by: 1