PROOF OF INSURANCE (2020) CLOSED A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
/0/1612016
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 I CONTACT David Irwin
NAME:
Keystone Risk Managers,LLC �MA
NE� (570)473-2150 FAX 611 (570)473-2151
1995 Point Township Drive IRtss: IlrwinKeysloneinsgrp.com
INSURER(S)AFFORDING COVERAGE NAIC S
Northumberland PA 17867 INSURER A: Lexington Insurance Company 19437
INSURED I INSURER B: AIG Specialty Insurance Company 26883
Little League Baseball Risk Purchasing Group,Incorporated I INSURER C:
EL SEGUNDO LL N INSURER D
1114 E Acacia Ave INSURER E
EL SEGUNDO CA 90245 INSURER F:
COVERAGES CERTIFICATE NUM'BER: 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.
INS'R' A001.SUSN I POLICY EFF POLICY'EXPLIMITS
LTR TYPE OF INSURANCE INSO POLICY NUMBER ;WMIDDIYYYY) IMWDDlYYYY)
COMMERCIAL GENERALLUIBILITY EACH OCCURRENCE I S 2,000,000
OAMAGE TO
® CLAIMS-MADE FRI OCCUR �I PREMISES tEaENTEO oumnance) S 300,000
I I MED EXP(Any one person) S Excluded
A X 011225826 101/01/2019 01/01/2020 PERSONALBADVINJURY 5 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE--5 2,000,000
�POLICY JEa E-1LOC PRODUCTS-COMPIOPAGG 5 2,000,000
OTHER; Per League SEXUAL ABUSEOCGAGG S 2M/$2M
AUTOMOBILE LIABILITY COMBINED SIN�GLE LI'MI'T S
4Ee a anti
ANY AUTO BODILY INJURY(Per person) 5
OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLYAUTOS
HIRED NON-OWNED PROPERTYDAMAGE IS
„ ... AUTOS ONLY q
AUTOS ONLY Par dent)
S
UMBRELLA LM OCCUR I EACH OCCURRENCE $
I EXCESSLIAryB CLAIMS-MAJ I AGGREGATE $
6 DEC) ti V RETENTIONS I y $
WORKERS COMPENSATION I I STATUTE I ER"*
AND EMPLOYERS'LIABILI Y Y I N
ANYPROPRIETORIPARTNERPExECUTIVE ❑ NIA V E.L EACH ACCIDENT S
RIM
OFFICEEMSEREXCLU'DED7
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
Wa,dourtbe under
DESCRIPTION Of OPERATION'S below EL.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required)
Certificate Holder is named as Additional Insured per form CG 2026(04/13)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of EI Segundo,Its Officers,Officials,Employees,Agents an ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street AUTHoRE"ED RF.PRES
EI Segundo CA 90245 ' .r
®1.988-2'015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE 1 DATE(MINDONY)
10/16118
PRODUCER CERTIFICATE#: 4053601-2019-1 4 05 36
Keystone Risk Managers,LLC
1995 Point Township Drive
Northumberland,PA 17867 INSURERS AFFORDING COVERAGE:
ADDITIONAL NAMED INSURED: INSURER A: I Lexington Insurance Company
EL SEGUNDO LL INSURER B: National Union Fire Insurance Company of
Ted Lappe (Non-Liability) Pittsburgh,PA
1114 E Acacia Ave AIG Specialty Insurance Company
EL SEGUNDO,CA 90245 INSURER C:
COVERAGES
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 i$ SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AOD`L I POLICY EFFECTIVE POUCY EXPIRATION LIMITS
LTR NAMED TYPE OF INSURANCE POLICY NUMBER DATE(MWDDNYYY) DATE(MWDDNYYY)
INSRD .. ......................
.............. GENERAL LIABILITY EACH OCCURRENCE $2,000,000
X - I-XOCCUPRENCE 011225826 01/0112019 01/0112020 GENERA�A0179EQATE $2.000.000
INCL PARTICIPANTS 1_X Property Damage Deductible:$250 PRODUCTS?GREGATCOME P OPS $2.000.000 AG
Sexual Abuse $2,000,000
OCCURRENCE
X SEXUAL ABUSE Sexual Abuse I $2,000.000
1 1 AGGREGATE
MEDICAL PAYMENTS Any One Person
EACH LOSS $1.000,000
A X DIRECTORS&OFFICERS 0191129346 01/01/2019 01/01/2020 CLA
EGATE $1'000,000CXCYBER LIABILITY COVERAGE 19326190 oj/0112019 1 01/01/2020 LIOTY $1 0 0.0100 PERIMS MADE LEAGUE AGGREGATE f
............
S&P SECURITY AND PRIVACY LtAoI�TY"" $100,000 PER 1-6661E SUBLIMIT`6FLIAB'ILITY RETROACTIVE DATE CONTINUITY DATE
INS RANCE $1,000 PER LEAGUE RETENTION I
I I I'll, I I I POLICY INCEPTION POLICY INCEPTION
REGULATORY ACTION SUBLImrr OF $100,000 PER LEAGUE SUBLIMIT OF LIABILITY
LIABILITY $1,000 PER LEAGUE RETENTION
EMEVENT MANAGEMENT INSURANCE $100,0010 PER LEAGUE SUBLIMIT OF LIABILITY NOT APPLICABLE POLICY INCEPTION
$1,000 PER LEAGUE RETENTION
A X CRIME COVERAGE 011408726 011101=1,9, 1 01/0 I'll,1 I'll 11 2020 EACH LO I S"I S"I'll $35,000
&ire 'Do d u"atible:$250 Property/$1,000 Money AGGREGATE NONE
II As in Master Policy: As in Master Policy
SPORTS EXCESS ACCIDENT SRG9105434 01/01/2019 01/0112020 Med.Max.$11010 Excess
Deductible $50 11
ADDITIONAL INSURED
Who is an Insured(SECTION 11)of the General Llobttfty policy is amended to"include as an insured the person or organization shown in the scheduto,but only with respect to
liability arising out of the above named Little League's maintenance or use of ball fields,or Other promises loaned,donated.or tamed to that Little League by such person or
organizations and subject to the following addIflonall exclusions:
1.Structural alterations,new construction,maintenance.repair or demolition operations performed by or on behalf of the person or organization designated in the Schedule and/or
performed by the above named Little Leaquo;and
2. That part of the balt field or other promises not being used by the above named Little League.
NAME AND ADDRESS OF PERSON OR ORGANIZATION:
City of El Segundo,Its Officers,Officials,Employees,Agents and Certified Volunteers
350 Main Street
El Segundo,CA 90245
INSURED .1 CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
Little League Baseball Risk Purchasing Group,Incorporated WITH THE POLICY PROV S.
539 U.S. RT.15 Highway
South Williamsport,PA 17702
AUTHORIZED/-PRESENITAIIVE
POLICY NUMBER: 011225826 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES T#E-POJ..ICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED --r:-DESIGNATED'
PERSON OR ORGAN-IZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)Or-Organization(s):
City of EI Segundo, Its Officers, Officials,. Employees,.Agents and ,
Certified Volunteers
350 Main Street
EI Segundo, CA 90245
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
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to liability for"bodily injury", "property If coverage provided to the additional'insured is
damage" or "Personal and advertising injury" required by a contractor agreement, th6 most we
caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the
omissions or the acts or omissions of those acting amount of insurance:
on your behalf:
1. Required by the contract or agreement;or
1. In the performance of your ongoing operations;
or 2. Available under the applicable Limits of
Insurance shown in the Declarations;
2. In connection with your premises owned by or
rented to you. whichever is less.
However: This endorsement shall not increase the
applicable Limits of Insurance shown in the
1. The insurance afforded to such additional
insured only applies to the extent permitted by Declarations.
law;and
2. It 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 0 Insurance Services Office, Inc.,2012 Page 1 of 1
U
•r
EI Segundo Little League Board of Directors
To: City of EI Segundo Parks and Rec
Fr: Ted Lappe- President of EI Segundo Little League
RE: Auto Insurance
Date: 10/16/18
To Whom it May Concern;
EI Segundo Little League does not carry any Auto Insurance as we have no Vehicles that are owned or
Operated by the League.
Regards,
Ted Lappe
President ESLL
PO BOX 112
EI Segundo, CA 90245
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 EI 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 EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of ent Phone#
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
e pioy 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 th orkers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisions c�g'reement will automatically become void.
Signature of Applicant „ ... y � ................. . _..._ Date.............1.1./L...// ............. ............
Agreement for. ...............
Dated: J
Reviewed by:
i-S, If
oo1