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PROOF OF INSURANCE (2020) CLOSED0' I DATE (MMIDDIYYYY) ACOOR "" CERTIFICATE OF LIABILITY INSURANCE 3/13/2019 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(les) 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 Sports ..,.. ...... RPS Bollin er PHONE 1-800-446-5311 973-921-8474 150 JFK Parkway E- " aExt)� ..................1...d „gJ Short Hills NJ 07078 ADL1A SPORTSERVICE I PSINS.com INSURER(S,)AFP,ORDING 0 OVERAG,E............................................,,, NAIC# INSURER A: Scottsdale Indemnity Company 15580 INSURED USAWA-1 INSURER B: 'National Casualty Company 11991 USA Water Polo Inc and its Member Clubs and Zones INSURER C: Hartford Life and Accident 70815 6 Morgan, Suite 150 JNsu.RffRp: Irvine CA 92618 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1637097478 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. ADt% ..... ............ BE iNTIi.....................................rrP E OF INSURANCE I POLICY NUMBER ..... . MIDDr Yyy'�F Pmpvff£XP /MMPODCfYYYI 19�fl�N�d�DPlYYY1 LIMITS A COMMERCIAL GENERAL LIABILITY Y 8L-KRI-00000076982-00 1/1/2019 1/1/2020 OCCURRENCE EACH r � CLAIMS-MADE[Xi OCCUR PREMISES pcGTy enr,„1,;000 1000000 000, ..X.. V X OwnersBContrctrs MED EXP (Any one person) _$ 5. DOD X 1.600,.......,..�.�.�.�............................ PERSONAL &ADV INJURY $ .000 APPLIES GEN'LAGGREGATEJECT POLICY PROT u i_X. OC II GG V PRODUCTSGCO,MP;OP.A............. $„2; 000GREGATE /,000m.!�.ed......,...— OTHER: Q Sexual Abuse/Mol $ $1Mil/$2M!l A AUTOMOBILE LIABILITY Y 8L-KKI-00000076983-00 1/1/2019 1/1/2020 COMBINED SINGLE t.IMIT jE.a ecggng ) $ 1,.QW1900 ANY AUTO BODILY INJURY Pererson p OWNED ALL OW SCHEDULED . Pera BODILY INJURY ( accident) $ AUTOS X NON OWNED Pi2d)PEF'tDbAMAU......... .... E „�X__ HIREDAUTOS AUTOS Vlcgp�zk'..'�li�..............................�......�.........$....,. B UMBRELLA LIAB X OCCUR Y 6L-XKO-00000076984-00 1/1/2019 1/1/2020 EACH OCCURRENCE $ 5,000,000 11 X EXCESS LIABt $ 5,000,000 �CLAIMS,m,M„A,D,E, DED RETENTION „AGG„EGATER, $ WORKERS COMPENSATION I PER OTH- f I I ER I' AND EMPLOYERS' LIABILITY Y / N ANY .-------�_$TATUTE ..... ........................ IDENT $ OFFICE /ME EXCLUDED? OFFICER/MEMBER EXCLUDED? N / A(Manda CEA HR/ E L DISEASE EMPLOYEE $ ... If yes, describe under DESCRIPTION OF OPERATIONS below E DISEASE -POLICY LIMIT C Accident Medical 36 -SB -204979 �I 1/1/2019 1/1/2020 Med Max $75,000 Deductible $500 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The certificate holder is named as an additional insured but only with respect to the operations of the named insured. This certificate is issued on behalf of: Trojan Water Polo (Ca) Group Code:'WP87 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, ACCORDANCE WITH THE POLICY PROVISIONS. agents and volunteers 350 Main St?;ir ESENTATIVE EI Segundo CA 90245 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 8L-KRI-00000076982-00 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURIN DESIGNATED PERSON O'tN- ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of EI Segundo, its officers, officials, employees, agents and volunteers 350 Main St EI Segundo CA 90245 �� -- (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 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: (_) 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 Name of Agent Policy Number Expiration Date Phone # i (� I 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 s I)jecl to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with tloos ra iisions or the agreement will automatically become void. Signature of Applicant 1 i n^J Date 3 I Si 9� `° Print Name Agreement for: , ► 1 V� V Dated: Reviewed b mow,