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PROOF OF INSURANCE (2020) CLOSEDRGN 0092 0, � DATE (MMIDD/YYYY) A"R" CERTIFICATE OF LIABILITY INSURANCE 711'012019, 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 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). ACT PRODUCER to C T.ilo. E <t): (800)872-2976i„i .....2J m1155 Concourse Cor orate Center Five PHONE paE 7961 INI Na): 3�_9,-5............5.... P g IMAEIL H................................. Ivillis insurance Services of Georgia, Inc. N 18th Floor E' - Atlanta, GA 30328 ADDRESS: pcgrt§@9y§2oT t -1-1111111111111 "I'll INSURER (S) AFFORDING COVERAGE NAIC # www.ayso.org INSURERA: Everest National 1nsuran.99.C2mpa9v 10120 INSURED American Youths Soccer Organization INSURER B AYSO gg�^ rmoOn NSURER C 19750 S. Avenue, Suite 200 INSURERD, ..... .. Torrance CA 90250 INSURER E ; _.................................................. INSURER F : COVERAGES CERTIFICATE NUMBER: 49905445 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. �N......., AM tld..i.11t1R TMP. ......................................_ D POLICY NUMBER ...................... ... .............................................. EFF POLICY EXP /tgipYI LIMITS � A COMMERCIAL aeluTY SIBML00321-191 7/1/2019 7/1/2020 $1...�a O�it� pQ ..' .............._ ��, - Ao10EVO.......... . 0 2Q0,000 CLAIMS -MADE OCCUR ru. �” , Pa„rl"cipan"t &Legal Liability _.. MED EXP (Any one arson,) „ P.... * $.10 Q0,0 _PERSONAL & ADV INJURY $ 1,000,000 ..................................... 'LAGGREGATE LIMIT "- 3,000,000 "S O LOC PRODUC SGGOMP/OPAGG ...�......�^,,,,,.,....... 3,000,000POLICY ...... ....,C....E.....i.. I OTHER: Per Re in(25M Pal Acg) $ I/ AUTOMOBILE LIABILITY COMaMNEO SINGLE It" $ ANY AUTO BODILY ) IJ,_. Y" A.........s...o....n.... $ ............� OWNEDSCHEDULED F—AUTOS .................a.,..... BODILY INtY(eraccident) $ .................... AUTOS ONLY .,. . .. ... ....." HIRED NON -OWNED DAMAGE $ AUTOS ONLY AUTOSONLY .".n A UMBRELLA AB LI OCCUR S18EX00267-191 7/1/2019 7/1/2020 EACH OCCURRENCE $4"0001000 .........^,..,., ✓ EXCES CLAIMS -MADE AGGREGATE ............. DED ✓ RETENTION $4^0000110.,m.. WORKERS COMPENSATION PER OTH- AND YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT EXCLUDED? NIA A OFFICER/MEMBEREXCLUDED7 ........................... MandaR/MEMBEREX (Mandatory ) E, L.DISEASE-EA EMPLOYEE$���X�m��m� .......................m...$....,......�. ....................... ... , If yes, describe under DESCRIPTION OF OPERATIONS below E1, DISEASE -POLICY LIMIT $ - A 'Abuse & Molestation S18ML00321-191 7/1/2019 7/1/2020 $1,000,000 Each Occurrence $2,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) "Med Pay applies only to spectators at an AYSO Event. Certificate Holder is an Additional Insured as respects AYSO sanctioned events only as per the attached endorsement. General Aggregate Limit Applies on a per Region basis. CERTIFICATE HOLDER RGN 0092 The City of EI Segundo, its officers, officials employees, agen#s, and volunteers 350 IMain St EI Segundo CA 90245 ACORD 25 (2016/03) CANCELLATION 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 g ' Britt Pyle ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 49905445 1 2019-2020 Master Certificate I Region 00927/10/2019 10:27:52 AM (PDT) I Page 1 of 2 This certificate cancels and supersedes ALL previously issued certificates. S18ML00321-191 7/10/2019 American Youth Soccer Organization AYSO Region 0092 COMMERCIAL. GENERAL LIABILITY ECG 20 600 05 09 THIS ENDORSEMENT CHANGES THE COVERAGE PART. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURED - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or or- ganization with whom you have a written agree- ment that such person or organization be added as an additional insured on your Coverage Part. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" but only to the extent 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 operations for an addi- tional insured. B. The insurance afforded to an additional insured shall only include the insurance required by the terms of the written agreement and shall not be broader than the coverage provided within the terms of the Coverage Part. The City of EI Seundo, its officers, officials employees, agen s, and volunteers . 356 Main St EI Segundo CA 90245 C. The Limits of Insurance afforded to an additional insured shall be the lesser of the following: 1. The Limits of Insurance required by the written agreement between the parties; or 2. The Limits of Insurance provided by this Cov- erage Pan`.. D. With respect to the insurance afforded to an addi- tional insured, this insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of any act or omis- sion of an additional insured or any of its employ- ees. ECG 20 600 05 09 Copyright, Everest Reinsurance Company 2009 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. 49905445 12015-2020 Master certificate I Region 0052 1 7/10/2019 10:27:52 AM (PDT) I Page 2 of 2 This certificate cancels and supersedes ALL previously issued certificates. Page 1 of 1 ❑ 7cyilh'Alovir, ("roov I F ,� lown V12"hIN"'A 9'7 U,alpj AA'�� lI� Rtf'dcovw 5! rlllP 9, min lrl,n P, I "lp iqb I; V, SCa v'r, !U kwr' vort llhalvINato kuap minxw, "ll; rplarl co aw,T VICQl"� I" V". ibOeh u id uv s try? Vll' SA'pv:� I lco� &� , �blt-ze oug 4 II5Olumv� CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING; FAILURE TO SECURE WOR S' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm urxiur penalty of iseilury tinder the lam of Cakforn o one of the lo3o ng declarations: ( ) I have and wd rnarrrgaMn a r�.- firala of consort of nett(- k insure for wor' compersation, issued by the Director of Industrial Rdabom as provided for by L.ahar Code § 3700 for the pw*rrrr%anoe of the work twt lorth the a9fccrrT wilt, thu City of El Segundo_ Poky No. U I hart: and will maintain workers compensation insurance as requwed by Labor Code § 3700 br ft perlormbnce of the work for which elle agreement with the City of EI Segundo is executed. My workers' caawensation insurance ewer and posi(.y numbuf ate Carrier Po" Numbor Expiration Dabs "N,1111JEN m iir; " Phone 9 M ('zz I canify that. in ft pwftmwm rn of the woW forth in the agreement wrth the Gly of EI SeSundo, I will not twVloy any parson in any roamer so as to ber4irrile subjecal to the worker$' Compensation lawn Of Callbmia, and agree that. if I should become subject to the +� .:r�' compensation provisions of labor Cods: § ' 3700 1 must irnmediately comply with those -mvnt we m*ornaiically become void. c"w 7 $igtt8ture4t J4pp1iC:'itttt AgrCE'fftCtlt fLK � or Dated: ��.i�'°w�m�t�.ut'' 't"