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PROOF OF INSURANCE (2020) CLOSED_--i 0 DATE (MM/DD/YM)
AC "R" CERTIFICATE OF LIABILITY INSURANCE
Awa...- 6/27/2019
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 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 .
Service
RPS Bollinger Pao¢ HON . rtk 1-800-446-5311
-8orts 0-446- .... a—.sFAX, N4 973-921 54.7....
150 JFK ParkwayEadr: 1-800 446 EFPIINS,calTa 4.___..... ..
Short Hills NJ 0778 ADDRESS: SPOPT'SE VI,..a._..
COVE
INSURER A: SCOttSdSURER(S),,,,A„FFORDING RAGE 5580
N
ale Indemnity, Cc pany 1
INSURER C : Hartford Life and Accident INSURED bar Clubs a usnwA-1 * ual Company
and pitsVMemberater Inc ant mm „ ��,,,,70815
and Zones INSURER B : National Cas
NsuRert D
..................................................... ..
Iry.INSURER E
9Suite 50
Irvine CA 2618 I.......m.........: u
INSURER F: N
COVERAGES CERTIFICATE NUMBER: 1637238399 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 TYPE OF INSURANCE S It POLICY POLICY EFF POLtlCY EXr
1 NUMBER WMIDI)M I /MMIDDNYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY Y BL-KRI-00000076982-00 1/1/2019 1/1/2020 _ EACH OCCURRENCE $ 1.000,000 -
__ _
OCCUR
X DAMADC
�.............� PA�„A„1,1,!„�5,.��.,,(�.�,.p„cG,urfenC,el $ 1.000,000
CLAIMS -MADE -
000
X OwnersBConbcVs ....... ......................................... MED EXP(... Any on,e person). ...$.,. $,.,... ..,,,
NAL & ADV INJURY $ 1,000,000
X Part Lap!„Lie..................................... ................. ....... _. —_ PERSO.............,..................
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ None/Unlimited
'
POLICY ECX LOC
P.R.ODUCT
S.-COMP/OPAGG $2,000,000
OTHER Sexual AbuselMol
__...........
$ $1 Mil/$2Mil
A AUTOMOBILE LIABILITY Y BL-KKI-00000076983-00 1/1/2019 1/1/2020 COMBINEDSINGLE LIMIT $
1,oQQ 29Q_...,.
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED .- SCHEDULEDBODILY
.__..................._.
AUTOS AUTOS PR4TEFt t7JfA4GE $
HIREDAUTOS AUTOS ( DaLco nABRY(Peraccidenq $
X
NON -OWNED ��
..............
$
B UMBRELLA LIAB XOCCUR Y 6L-XKO-00000076984-00 1/1/2019 1/1/2020
EACH OCCURRENCE ........... 8.5,000e.000
X EXCESS LIAR CLAIMS -MADE AGGREGATE $ 5„000000
DED RETENTION $ $
WORKERS COMPENSATION IPER 01 H-
AND EMPLOYERS' LIABILITY Y / N ........,.1, sTA741T�1.......___..._�R'ANY ..
...A...... � $
OFFICER/MEMBER EXCLUDED? PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E L EAC ACCIDENT M
(Mandatory ) DISEASE- EMPLOYEE $
Mandato m NH _E,.L._........._..................................... .......
If yes, describe under
DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $
C Accident Medical �� 36SB-204979 1/1/2019 1/1/2020 Med Max $75,000
Dedud6bie $500
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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:
South Bay United Water Polo Club
Group Code: WP1280
I
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 AUTH RIZE'D REPRESENTATIVE
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.
ADDITIONALDESIGNATED PERSON OR
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 2611 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.
LJ 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 # .............................................................. .
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 'sub' t to t e w ers"' compensation provisions of Labor Code § 3700 I must
immediately comply with those s: e, Lautomatically become void.
Signature of Applicant - Date z
Print Name �eAAx