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PROOF OF INSURANCE (2019) CLOSED
I DATE:(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/14/2018 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 Frazier Insurance Agency, Inc. NAME PYRONE Frazier Insurance Agency, Inc. (A/C,No.EM). (804)754-7610 FAX No): (804)754-7613 P.0 Box 1250 E-MAIL Midlothian,VA 23113-1250 ADDRESS: ifrazier@frazierinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA United States Fire Insurance Company 21113 ...., .• W W................................�. .•.•.•.•.•.•.•......�� INSURED INSURER B Sports 8 Recreation Providers Assn Risk Management,Inc INSURERC EI Segundo Inline Hockey Association PO Box 3061 NSURERD EI Segundo, CA 90245 INSURERE INSURERF 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLI TIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000.00 y X PRODUCTS-COMP/OP AGG $ 2,000,000.00 WplWY.flk:PCIftL GF_FIF_F'l61.LIAF7II_!7Y 11_AI1n1-.1.1 X —CUR PERSONAL 8 ADV INJURY I $ 1,000.000.00 A SRPGAPML-101-0718 $ 1,000.000.00 11/28/2018 11/2812019 EACH OCCURRENCE INCLUDES ATHLETIC PARTICIPANTS 12:01 AM FIRE DAMAGE(Any one fire) $ 300.000.00 CFfBL AGGREGATE LIMIT APPLIES PER MED EXP(Any one person) $ 5,000.00 AUTOMOBILE LIABILITY o;suEnrr,^?"dtim;i;;,Yi.ud,+'" I $ e a'r n.nic• BODILY INJURY(Per person) $ BODILY INJURY(Per accident) A1t9 r�xi,.,liu:YiIir:, G $ ............ $ UMBRELLALIAB EACH OCCURRENCE $ IEXCESS LIAB C1 AIMS flgn+V'•w'. I AGGREGATE $ $ $ I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AttachACORD 101,Additional Remarks Schedule,if more space is required) I POLICY DEDUCTIBLE. $0 00 PER EACH BODILY INJURY OR PROPERTY DAMAGE CLAIM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo Inline Hockey Association ACCORDANCE WITH THE POLICY PROVISIONS PO Box 3061 EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE john'W. (Frazier ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Insured: EI Segundo Inline Hockey Association Policy Number: SRPGAPML-101-0718 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name ..Of..Ad....Additional Insured Person(s) ....... ................ _._...__...�................................................................................._.... d i ' ) Organization(s) The City of EI Segundo 350 Main Street EI Segundo, CA90245 ............................... ............................................. ................................................ Information required to complete this Schedule, if not shown above will be shown in the Declarations. ............................................................................ _................................................ ............. Section II - WHO IS AN INSURED is amended to include as an insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury" caused, in whole or in part, by your acts or omissions of the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ _0 El Segundo nll*ne Hockey Association Auto Insurance 11-6-17 To Whom It May Concern, The EI Segundo Inline Hockey Association does not have auto insurance as part of our organization. Regards, Jeff Tiddens ESIHA Board President Page i 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# (X ) I certify that, in the performance 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 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 Date 10-30-17 d legundo Inline Hockey Association Agreement for: TrT Dated: Reviewed by: