Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PROOF OF INSURANCE (2020) CLOSED
'a DATE(MMIDD/YYYY) A'�'+�"R " CERTIFICATE OF LIABILITY INSURANCE �� .. 05/29/2019 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 ra Willi3 s Risk Management Services, Inc. PHONE D602) 841-32a4 �p„No);(,a............m...........,,,,, AI!CG__ 6�I(%. ) 274-9138 P.O. BOX 32712 E"MAYL dwilliame theriskpeopl,e.com Phoenix AZ 85064-2712 gruRE.AS INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: National Casualty± ......................... 1199.1 INSURED (310) 994-7946 INSURERB:Gerber life Insurance Cc 70939 Swimming Los Angeles — (Jarcyn Amateur Swim Assoc Corp) INSURER O: 16634 Calneva Drive I I" Encino CA 91436 NSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: cert ID 22976 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. TYPE OF INSURANCE .... SD MU9k POLICY ---_. _ --- .* ,,.. ........ ILTR �AN [dIL.`t)'F! ...NUMBER .... POLICY EIFF POLICY EXP.. ..... LIMITS PMMI'OgIYYYYI I'�VI „PC91D,1'rfY'YY1 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ 2,000,000 _ DAMAGE TO RFNTFY7................. CLAIMS -MADE �X OCCUR Y Y KRO-79931-00 N 05/30/2019 05/30/2020, SES, Ea occurrence ) 300,000 X ParticipantLeal � MEDEXP(An � onepers on) $ EXCLUDED X Liability ed PERSONAL Y SPER: EN'L AGGREGATE LIIMIITAPPLIE GENERALAGGREGATE $ UNLIMITED mmm„m POLICYF—]JECT LOC ❑ . 2, x i OTHER; ABUSE/MOLESTATION $ 290,..000........ AUTOMOBILE LIABILITY YCOMBINED WGI.ELIMIT $ 1,000,000,m,m,m,m,,,,,, A ANY AUTO Y Y KRO-79931-00 N 05/30/2019 05/30/2020, BODILY INJURY (Per person) $ OWNED accident) $ OONLY AUTOS NON -OWNED .._..i.3...P....ER"NTJ..0. DA .(Per F Y— $$ XAUTOS ONLYX .. AUTOS ON _. .......m.. UMBRELLALIAB OCCUR XEDESSLIAB I V CLAIMS-MADEI ..D..............-'"1...RETENTION $ WORKERS COMPENSAT10N AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE F7 NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below B XS Medical/Dental 03-071691-19 EACH OCCURRENCE AGGREGATE ....L.$....................... III, $ ...................... _LSTATU.T .t-........� .R.H................... E EACH ACCIDENT E DISEASE - EA EMPLOYEE $ E DISEASE -POLICY LIMIT $ 05/30/2019 05/30/2020 Maximum Limit A D & D 11 Maximum Limit DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Verification of General Liability coverage for Swimming Lessons. Excess Medical/Dental coverage provided for the Insured's Participants only. A 30 Day Cancellation notice applies per policy provisions.The City of El Segundo, its officers, officials, employees, agents, and volunteers are named Additional Insured as respects General Liability and this insurance is primary and noncontributory with any other insurance but only as respects to the Named Insured's operations at Urho Saari Swim Stadium, 219 W Mariposa Ave, E1 Segundo, CA 90245. CE'RTIF'ICATE HOLDER City of El Segundo 350 Main St E1 Segundo CA 90245 1 ACORD 25 (2016/03) CANCE'LLATI'ON 25,000 5,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �boxwo ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Page 1 of 1 POLICY NUMBER: KRO-79931-00 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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) City of EI Segundo, its officers, officials, employees, agents, volunteers 350 Main St. EI Segundo, CA 90245 RE: Swimming Los Angeles Location(s) Of Covered Operations 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 include as an additional 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional 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 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 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: LJ 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 U 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 Agent Phone # AIN I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not mploy 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 l must immediately comply with those provisions or the agreement will automatically become void. Signature of A pplicant �-� Date Print Name , 'L �mn�i Agreement for: .. . � � . Az Dated: c2 7 - Reviewed by: �"