PROOF OF INSURANCE (2020) CLOSED0 DATE(MM/DD/YYYY)
ACCA?" CERTIFICATE OF LIABILITY INSURANCE Vul
06/14/2019
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(ios) 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 endorsemont(s).
CONTAPRODUCER LEONARD ZAHLER, C.L.U, I sK: IL, ONARD ZAHLER CA BROKER
, F C 0324698
PHOENIX INSURANCEAGENCY
PHONE c,i) 661) 212-' 2 N �• 661 . 885 4244
ZAHLER INSURANCE G ADDRESS THOROUGH BRED0.0.1_@AOL..C.OM
„ .., SURER,ISI„ AFFORDING COVERAGE' 1 NAIC 0
.17354
INSURED )NSURER,9,_MUTUINSURANCE
, 03285
P.O.N
BAKER SOCCER CSOUTHBAY REFER .PHILADELPHIA INSURANCEISURAN COMPANY I
N � 03285
INSURER a
C/O EE ASSOCIATION INSURER C:
AL OF OMAHA
MICHAEL HINTZ & BRUCE ASHTON
INSURER R;
9045 HARGIS STREET INSURERE
LOS ANGELES, CA 90034
INSURER F ;
COVERAGES CERTIFICATE NUMBER: 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.
INSR ,INF .... I
TYPEOFI,-- ��kkk . jiTOLICYEPF POLICY EXP I, LIMITS
LTRINSURANCE L'v�r� POLICY NUMBER tl4kMiIDO�..__.CPAMd097dA°YYYY
A X
COMMERCIAL I CLAIMS ADE XI OCCUR GENERAL LIABILITY X X PHUB461338 01/1/2019101/112020;. E SFS( ouuE non?)
$ 1000,000
00,000
XP
,,,... ..., PERSONAL B ADV. I?, .,
( r, INJURY $ 1,000,000
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER' 3,000,000
❑ PR DUCTS AGG $ 3,000,000
PRO- P
X POLICY .....,, JECT LOC i
I OY'HER i $
AUTOMOBILE LIABILITY
Y`,4'7'MiSYtlIF"7 ,.tlNI'7LE LIMIT $
ANY O
BODILY NJURY
r.eef
OWNED SCHEDULED
den- $
BODILYIINJ`URY (Per coon t)
AUTOS ONLY AUTOS
RED NON -OWNED
„ry M6';'YPI HV'N' D4�IA1 AiCSL
AUTOS
� AIUTOS Y ONLY
r
UMBRELLA CUR
BTENTION
EACH OCCURRENCE
EXCESS SLIABR LAIMC m�1FIDr
CL ....... :,
AGGREGATE ,$,,,, __
/•N
DED E $
PER OTH-
,
WORKERS COMPENSATION
STATUTE �„ER
O,
YIN
ANY IPAR N
6
EACH ACCIDENT $
ACC
��•'u d\
i
ICERPRIETO
EXCLUDED? ❑
(M nde orym NHR/PARTNER/EXECUTIVE NIA
......
EL, DIS EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below
E L DISEASE - POLICY LIMIT $
b
B
ACCIDENTAL MEDICAL T5MP-096103
ACCIDENTAL MEDICAL $ 25,000
1/1/2019 1/1/2020 /
PAYMENTS // REFEREES
ACC. DENTAL/ THERAPY/ ACC.
LOSS OF LIFE $ 101000 /
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace is required)
ALL ACTIVITIES OF THIS INSURED.
ADDITIONAL INSURED: THE CITY OF EL SEGUNDO, CA
- ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND
VOLUNTEERS ARE HEREBY NAMED ADDITIONAL INSUREDS.
30 -DAY WRITTEN NOTICE SUBMITTED TO CERT. HOLDERS AND ADDITIONAL INSUREDS IF POLICIES TERMINATE PRIOR TO
EXPIRATION DATES SHOWN ABOVE. ENDORSEMENTS ATTACHED HERETO.
CERTIFICATE HOLDER
CANCE'LLATI'ON
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE CITY OF EL SEGUNDO, CALIFORNIA
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
C/O SHAWN GREEN, RECREATION SUPERVISOR
.
ACCORDANCE WIT P OLICY PROVISIONS.
350 MAIN STREET, EL SEGUNDO, CA 90245
Ile x � r ^
AUTH IyJ'!� Rp, �• , ,":•.
EOVRei ZAHL (�k” C
_ .....-..s.' ..
1888-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo
are registered marks of ACORD
SCHEDULED ADDITIONAL INSURED -PRIMARY
AND NON-CONTRIBUTORY
This endorsement modifies insurance provided under the followi%.
COMMERCIAL GENERAL UAS)UTY COVERAGE POL/ PHUB461338
PRODUCTSICOMPLETED OPERA-11ONS LIABIUT YCOVERAGE
The City of El Segundo, CA., --its officers, officials,
Employees, Agents and Volunteers,--ajze..hereby named
Additional Insured.
Who is an 'Insured' is amended to include as an insured the person or organization shown in the
Schedule as an AddffionW Insured, but only with respect to liability arising out of 'your work' or
'your product which is imputed to the Additional Insured.
The insurance provided to the Additional Insured under this endorsement is limited as follows:
I ll io Wl li"AW11111W,
-may
3. In the event that the limits of, Insurance provided by this policy exceed the Umfts of
Insurance requimwd by the written corrtract or v4iften agreemeM the insurance provkled by
this eridorsement shall be limited to the Limb of Insurance required by dv written ContraCt
Or written agreement This endorsement shall not increase the Limits of Insurance stated in
the�-_orvq_
4- This insurance does not apply to -bodily injuryor �property damagW aftng cxA of 'your
woW oryour producf included in the �products — completed operations hazwT uniess
you am required to provide such coverage by written contract or written agreement but ordy
for tie period of time requhed by the written contradl or written agreement and only ibr
'bodily injuy orproperty damage Inatoccurs during the Policyperiod arising out of 'Your
woW or 'y= producf.
5- Where no coverage shall apply herein for the Named Insured, no coverage or defense shall
be afforded to }he Additional Insured.
6. This insurance does not apply to -bodily injury' or 'property damage arising out of
a. the sole negligence of the Additional Insured,
b. the sole negrigenc;e of any employee of the Additional Insured; or
c. any obligation of the Additional Insured to indemnify anod-w because
of damages arising out of such injury or damage,
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
AP2057US 0307 Page 1 of 1
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION WHEN REQUIRED IN A WRITTEN
CONTRACT OR AGREEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The TRANSFER OF RIGHTS OP RECOVERY AGAINST OTHERS TO US Condition (Section P4 — COMMERCIAL
GENERAL LIABILITY CONDITIONS) is deleted and replaced by the following:
We waive any right of recovery we may have against any person or organization against whom you have agreed to
waive such right of recovery in a,wdtten contract or agreement because of payments we make for Injury or damage
arising out of your ongoing operations or "your work" done under a contract with that person or organ , ton and
included in the "}products -completed operations hazard".
CG7555(11-04) Includes copyrighted material of ISO ftl)Kfies, Inc. vAth Its permission, Page I of 1
4MERCURY" CALIFORNIA EVIDENCE OF LIABILITY INSURANCE
AO INSURANCE MERCURY INSURANCE
COMPANY
AGEIICY LITTLETON INSURANCE SERVICES 13101370 1597
POLICY NUMBER EF=ECTIW & --XPIRATsON DATES
0401 07'007495855 0210712016 08/0712019
YEAR MAKE VEHICLE IDENTIFICATION NUMBER
2004 BMW WBASW53464PL40265
NAMED INSURED
COLLEEN A HINZ
ADDITIONAL DRIVER(S)
MICHAEL HINZ
To REPORT A CLAIM, ploaso call 18001503,3724
For actor w ROADSIDE ASSISTANCE OWY, plew call n850 519.6478
Thim mouramce comtoliet woh CVC 516056 at S16500.5 NAICN 27563
V
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
A
I affirm under penalty of perjury under the laws of California one of the following declarations:
L_) 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 El 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 El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier
Name of Agent
Policy Number Expiration Date
Phone #
(Yo I certify that, in the performance of the work set forth in the agreement with the City of El 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 provisions or the agreement will automatically become void.
Signature of Applicant Date 6 -1 r - Zav�
—
Agreement for: 5CW Pr.661,i i PO4,57+),
A00n
Dated: 0/
Reviewed by: