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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE du 07/30/2018 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 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 CONTACT .. .. ... ... NAME: American Specialty Insurance&Risk Services, Inc PHONE No,� Y) 260-969-5203 RAX„ Ned, 260-969-4729 dba A.SJ.R.S.I Insurance Agency a'DMPILss 7609 W.Jefferson Blvd,Suite 100 INSURER(S)AFFORDING COVERAGE NAIC# Fort Wayne IN 46804 INSURER A: Arch Insurance Company 11150 INSURED INSURER B National Association of Sports Officials(NASO) INSURER C 2017 Lathrop Avenue INSURER D INSURER E Racine WI 53405 INSURER F: COVERAGES CERTIFICATE NUMBER: 1001593268 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. INTR ADDL ..., TYPE OF INSURANCE IN59-un POLICY NUMBER 1M /DEFF PM,D1YEYP POLICY OIVYVYI WMMI'DDIYYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR VIRE �L,S rE �;�x��of el,":ea S 1,000,000 MED EXP(Any one person) $ Excluded A Y SBCGL0279601 08/01/2018 08/01/2019 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APP LIES PER GENERAL AGGREGATE 5 5,000,000 L I P"y0„ Loc PRODUCTS-COMPIOPAGG „S 5,000,,000 POLICY ,J1m L••I X G'T'IP.IR OFFICIAL AUTOMOBILE LIABILITY C,f BIM1tlE.0;5,INf�Lk Cllr I) LIMIT $ I . 6C1t�S'S , , ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY 0A,M,e"aiW F $ AUTOS ONLY AUTOS ONLY y'E�air a�,r:ir,Yen"ro $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 5,000,000 A X EXCESS LIAB CLAIMS-MADE SBFXS0044401 08/01/2018 08/01/2019 AGGREGATE $ 9,000,000 DED RETENTION S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE 0 NIA EL EACH ACCIDENT $ E OFFICER/MMBER EXCLUDED (Mandatory in NH) E L DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Coverage applies to JOHN ZIELLO,704 CAMINO REAL,REDONDO BEACH,CA 90277 The Certificate Holder is only an Additional Insured with respect to liability caused by the negligence of the Named Insured as per Form 00 SGL0026 00 Additional Insured-Certificate Holders,effective August 01,2018, CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO,ITS OFFICERS,OFFICIALS,EMPLOYEES„ AGENTS,AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED American Specialty Insurance&Risk Services,Inc National Association of Sports Officials(NASO) .... ....................__.......,..,.,.,..._.........., POLICY ..�.,...m.,....... .,__.....,.,.,.,.,.,........... UMBER 2017 Lathrop Avenue SBCGL0279601 Racine,WI 53405 Arch Insurance Company 1115 f CARRIER NAICC ODE Q EFFECTIVE DATE: 08/01/2018 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ....,,,,, -Certificate#1001593268 ACORD 25 CERTIFICATE OF LIABILITY INSURANCE-C Unintentional Errors&Omissions,$100,000 each wrongful act/$100,000 Annual Aggregate per official/assignor Other Named Insured:National Association of Sports Officials(NASO)&NASO-member officials,including officials enrolled by associations,contracted with NASO, -Other Named Insured(cont'd):but only while acting in their capacity as officials during sports events organized by a recognized sanctioning body or organized by another entity,but the rules of a recognized sanctioning body are followed,such as local Park Department or any formal organized association, and/or while attending seminars,conferences,and similar meetings designed to improve their officiating knowledge and skills. -The excess Aggregate Limit applies separately to each"official"insured under this policy. However,in the event of a suit by one or more plaintiffs against more than eight"officials",the Aggregate Limit will not apply separately to each"official",and a single aggregate limit of$20,000,000 will apply collectively to all individual"officials"covered under this policy. i 6 � ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: SBCGL0279601 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location( Of Covered Operations CITY OF EL SEGUNDO, ITS OFFICERS, ELECTED AND APPOINTED OFFICIALS, EMPLOYEES AND MEMBERS OF BOARDS, COMMISSIONS and volunteers 350 Main Street EI Segundo, CA 90245 but only with respect to John Ziello Information required to complete this Schedule, 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 additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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 10 04 13 ©ISO Properties, Inc., 2004 Pagel of 2 0 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 0413 ©ISO Properties, Inc., 2004 Page 2 of 2 0 EVIDENCE OF INSURANCE COVERAGE Insurance identification cards are provided below. Please retain one card in the referenced vehicle. An additional card is available as required by some states for vehicle registration. CSE provides insurance information electronically to the CA, AZ and NV Department of Motor Vehicles. 0%:)�'" California Proof of Automobile AM OW�"' California Proof of Automobile "" Liability Insurance Liability Insurance $Ni6RRANC'C GROUP NAIC 10693 INSURANCE GROUP NAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins com caryb@basins com 704 CAMINO REAL 1704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address 730 S PACIFIC COAST HWY#201 730 S PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 1 REDONDO BEACH,CA 90277 Policy Number: CAA8002278 Policy Number: CAA8002278 Effective Date: 11/11/2018 Effective Date: 11/11/2018 Expiration Date: 05/11/2019 Expiration Date: 05/11/2019 Ph.800-888-7187 Fx 310-540-2215 Ph.800-868-7187 1`010-540-2215 Year/Make/Model VIN Year/Make/Model VIN 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 2012 FORD TRANSIT CONNECT XLT NM0KS9CN9CT113461 California Proof of Automobile &W sm California Proof of Automobile CS Em Liability Insurance CQU Liability Insurance INSURANCE OR 4 NAIC 10693 IN$UAANCE 90UP NAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins com caryb@bisins com 704 CAMINO REAL 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address 730 S,PACIFIC COAST HWY#201 730 S PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277 Policy Number: CAA8002278 Policy Number: CAAB002278 Effective Date: 11/1112018 Effective Date: 11/11/2018 Expiration Date: 05/11/2019 Expiration Date: 05/11/2019 Ph,800-868-7187 Fx 310-540-2215 Ph.800-888-7187 Fx 310-540-2215 Year/Make/Model VIN Year/Make/Madel VIN 2016 FORD EDGE SEL 2FMPK3J91GBB60321 2016 FORD EDGE SEL 2FMPK3J91GBB60321 CITY lDECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL 1 ($100,000), ), I IrlCOMPENSATION, DAMAGES AS FOR IN LABOR CODE § 3706, l , AND ATTORNEYS FEES. I affirm under penalty of pejury 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 worker's'Gompensation insurance as required by Labor Code§3700 for the perforTnance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance mer 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 El Segundo, I will not M oy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subj,eol to theworkers' compensation provisions of Labor Code § 3700 1 must immediately comply with thu s ro i '�n ....,r, will �.. �wen ra u .t.omati lly become void. Signature of Applicant D ate L. L Print Name Agreement for: Dated: Reviewed y: —1