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PROOF OF INSURANCE (2019) CLOSED AC CERTIFICATE OF LIABILITY INSURANCE °ATE(M0/2018 Y' �,,,..-m I 11/30/2018 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: Richard Chappell PHONE Deb ........................._. 447-6797 FAX 804-733-2968 2 807AICox Roade Agency ADDRESS; 800. ................ m IAdc,Ner, AIC,Nlr ExIIt _.�. AIL I Petersburg Virginia 23803 bie@chappellinsurance.com CUSTOMER I0. INSURER(S)AFFORDING COVERAGE NAIC# ............... . ............_._....................... INSURED INSURER A: Nationwide Mutual Insurance Company 23787 m.......,,, ............................._. South Bay Youth Sports INSURER B: DBA:Go Loon Sorts _...._....._. .................._ ................ g p INSURER C: 531 Main Street,#321 EI Segundo,CA 90245 INSURER D: A Member of the Sports,Leisure&Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01348677 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. I149k TYPE OF INSURANCE ADDL SU6k POLICY NUMBER POLICY EFF POLIIJY expLIMITS LTR INSO WVO (MMIDDIYYYY) (MM/DD/YYYY) II A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006430100 12/15/2018 12115/2019 a EACH OCCURRENCE $2,000,000 .................. CLAIMS- X1 12:01 AM EDT 12:01 AM DAMAGE TO RENTED MADE Y OCCUR PREMISES(Ea Occurrence) $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS–COMP/OP AGG $2,000,000 .........._.........._. POLICY PRO LOC PROFESSIONAL LIABILITY $2,000,000 ..._..... ............. PR _------ -..... ................ .........._.. OTHER: LEGAL LIAB TO PARTICIPANTS $2,000,000 ' A AUTOMOBILE LIABILITY 6BRPG0000006430100 12115/2018 12/15/2019 COMBINED SINGLE LIMIT $2,000,000 ••••••- 12:01 AM EDT 12:01 AM (Ea LY INnkl _.. ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ........... SCHEDULED ONLY AUTOS BODILY INJURY(Peraccident) HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X1 AUTOS ONLY (Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED 1-1 RETENTION WORKERS COMPENSATION AND N/A PERI OTHER EMPLOYERS'LIABILITY _I STATUTE u ANY PROPRIETOR/PARTNER/ Y/N E L EACH ACCIDENT EXECUTIVE OFFICER/MEMBER � EXCLUDED?(Mandatory in NH) E L DISEASE–EA EMPLOYEE If yes,describe under DESCRIPTION E DISEASE–POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000006430100 12/15/2018 12/15/2019 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Sport(s):Football(Flag&Touch)Age(s): 12 and under,13-15 The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE uea%,mimr-U POLICIES BE CANCELLED BEFORE 350 Main Street ITHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo,CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. (Owner/Lessor of Premises) I AUTHORIZED REPRESENTATIVE Coverage is only extended to U S.events and activities, "'NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006430100 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Additional Insured Person(s)Or Organization(s) Palos Verdes Peninsula Unified School District 375 Via Almar Palos Verdes Estates, CA 90274 Insured: South Bay Youth Sports DBA: Go Loong Sports Cert#5958 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 is added to Section organization(s) shown in the Schedule, but only with III—Limits Of Insurance: respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" caused, required by a contract or agreement, the most we will in whole or in part, by your acts or omissions or the pay on behalf of the additional insured is the amount acts or omissions of those acting on your behalf: of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement;or or our remises owned b or 2. Available under the applicable Limits of 2. In connection with Y P Y Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the applicable 1. The insurance afforded to such additional 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 ©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: 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. (_J 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# ( ) 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 shoutd a subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply w h rhos provisions ort a agreement will automatically become void. Signature of Applicant Date 1 125 Agreementfor: Dated: "` I Reviewed by. 1 -A TH 84), ww S SPowes 531 Main Street,#321,El Segundo,CA 90245 www.southbavvouthsoorts.org To Whom It May Concern: CERTIFICATION OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE This letter has been written to inform you that South Bav Youth Sports does not carry Workers Compensation Insurance by State of California as we do not have any employees. All workers for our agency are either volunteers or consultants. Business Automobile Insurance South Bav Youth Sporls do not own or lease a Business Automobile. Licensee: Joe Wang, President