PROOF OF INSURANCE (2020) CLOSEDDATE (MM1DD1YYYY)
CERTIFICATE OF LIABILITY INSURANCE 02MW2019
THIS CER'TIF'ICATE IS ISSUED ASA MATTER OF INFORMATION ONLY ANDCONFERS 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 DOE'S NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I'NSURER(Sb AUTHORIZED'
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the Pollcy(ies) must be endorsed, It 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
RPS Bollinger
1950 JFK PARKNAY, ATH FLOOR'
PO Box 390
SHORT HILLS, NJ 07078
PHONE: 1-800-446-5311 FAX: 973-921-8474
INSURED
USA Softball and Members of USA Softball of SDCal Indiv Reg
Program
Phil Gutierrez
PO Box 5028
CONTACT
NAME:
PHONE FAX
OX,No_E%tl; 800-46-5311 WC, u& .973-921,8474
E-MAIL,
ADDRESS:
INSURERISI AFFORDING COVERAGE NAIC N
INSURERA: Markel Insurance Company 399M
INSURER 6:
NINSURERC:
I INSURER D:
INSURER E:
Oceanside, CA 92052 INSURERF: I G
COVERAGES POLICY CHANGE NUMBER:IR0201961132 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
Cn' Vf�E3iLITY X I POLICY NUMBER LIMITS
IfR INSR VVVO (NaYDDIYYYYI t Y 1
ENERANSR TYPE OF INSURANCE ia.
4 X COMMERCIAL GENERAL LIABILITY
�l t'Jim� I m .0 I ®
CLAIMS -MADE ,CUR P a
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f Sl„N,.J:UrXt
(Alla O i $1tJ. AVS
X Participants Liab *Ncia-participantsanl.° mwxk 7t<AL7� twurw' .
GEEIMAGGREGATE S5_(YN.m,7tbV 1
LIMIT APPLIES PER: Scvvaal.l ua� f hCd9=,aa=.uar Lisp accwarren r S P u,:I:l P S- Tv
AGG . j
GEN'LAGGATE POLICY
RE PRO- �y IU)C tAtimm&Nfoletation.#t�^ta aril' limit: $
JECT II 1l` '�
AUTOMOBILE LIABILITY COMINtED SV431E UMIT iEa a=klisl> S
ANY AUTO
IDODLY KJLIRY arwr..rrosnSan5 S
ALL OWNED SCHEDULED OODty AWRY qwa=>;
AUTOS AUTOS PROPERTY DAMAGE S
HIREDAUTOS NON NED pPra
.
AUTOSu �
UMBRELLA LIAR CUR EACH OCCURfWJ4CE
EXCESS LIAB CLAOAS- GATE �I
DED F] RETENTION S
WORKERS COMPENSATION ITORYUMMS STATU-AHD EMPLOYERS°LIABILITY s
ANY PROPRETORPARTNERE MCUTTYE Y ! N ry
OFF ^aOZ- ro'V! ^'EER EXC D' N ! A I El EACH ACCIMW $ q
(Mandatory In NHI1
Pr�S N I �, E1 D6EASE-EA EMPLOYEES
T E 1. L:Js:6:.A,al” ':.. IW",.tl:,w LEB�R�1' S
OPERATHER
DESCORIPIMN OF OPERATION S r LOCATIONSVEHICLE�Att 'ch ACORD 101, Additional Remarks Schedule, if more space is require11 d
COVERAGE UNDER THIS POLICY SHALL APPLY TO LIABILITY OF THE INSURED ARISING OUT OF THE ADMINISTRATION, PLAY OR PRACTICE OF AMATEUR SOFTBALUBASEBALL,
BUT ONLY FOR INCIDENTS INVOLVING BODILY INJURY, PERSONAL INJURY OR PROPERTY DAMAGE. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED. THIS
C'ERT'IFICATE IS ISSUED Oft BEHALF OF. EL SEOUN'DO GIRLS SOFTBALL,
CERTIFICATE HOLDER CANCELLATION
City of Et Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
350'. Iain Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1E1 Segwdo, Ca 90245 ACCORDANCE WITH THE POLICY PROVISIONS,
tt�� r
AUTHORIZED REPRESENTATIVE
e^r 25 (2010105) The AC•RF name and logo are registered mairics of ACORD
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION FOR
USA SOFTBALL ACTIVITIES
This endorsement modifies insurance proNvided under the follomine.-
COAMERCIAL GVsTRAL LLILBELFTY COITRAGE FOKM
lVith respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
Nww afinsumd
USA ScftWl znd 'Mwnbets wl"USA Sofflxtll of SoCil hidiv Reg Ptopun
City of El Sepndo
Potiqr Nuinter Poli_7iod
36021AH.230069 1,1.2019 - M.12020
Lmrd By Audwnzed RepmPr=ive
AIAML M1113tANNE COMRANY 1�
The above =tmalim is fqixld only tater t5 vvwied da da Policy n araed
MN061 *110 14,
Name of Person or Organization:
As Show on the Attached Certificate oflusurance
A. The follo%xing is added to Section H-WHOISAN MURM
Endmemm3 uive Date
As dmm on iha attachW C,,.ftd:w� effInmmame
The person or organization shown in the above SCHEDULE but only with respect to liabiliry arisingaid
out of the organization,
promotion, administration and conduct of amateur softball activities, including games, practices, tournaments, and fund-raising
activities, under the rules of the USA Softball. provided;
a. That if the person or organization is designated as a Team, the person or organization so designated shall be deemed to
include tewn members, managers, coaches, assistants, batboys, registered scorekeepers, sponsors, any other individual
participating in the official functions of the team, and if so indicated, a Field Owner, but on1v for fiabiliry arising out of the
designated Team's ainateur softball acwiries covered under this policy:
b. That if the person or organization is designatedLeague not be included unless at teams
as a League, the interest of the League s
in the League purchase this insurance. When the interest of the League is so included, the person or organization designated
as a League shaft be deemed to include all teams in the league and team members, managers, coaches, assistants, batboys,
registered scorekeepers, sponsors, any other individual participating in the official functions of the League or of any such
teams. and if so indicated, a Field Owner, but on1v for liabihvv arising out of the designated League's ainateur softball
activities coveted under this policy;
All other terms and conditions of this policy remain unchanged-
�11'r I /11�
2 e Kral nye_
0
Nd CA ry-Y .q -w4 n ce .
p -,-
C-5 C, 5 A -Y,
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 forthe 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
Name of Agent
Policy Number Expiration Date
Phone #
(� 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 provisio s -of the agreement will automatically become void.
Signature:of Applicant: J! ``"" Date 12-115,
Agreement for: 0, , ," i : ' ' 'I "IVA
f.�
Dated: P
Reviewed by: