SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A : NAIC #
NAME: CONTACT
(A/C, No): FAX
E-MAIL ADDRESS:
PRODUCER
(A/C, No, Ext): PHONE
INSURED
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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).
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.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR WVDADDL
INSD
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. $
$
$
$ PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person) COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEEE.L. EACH ACCIDENT EROTH- STATUTE PER
(MM/DD/YYYY) LIMITS POLICY EXP(MM/DD/YYYY) POLICY EFFLTR TYPE OF INSURANCE POLICY NUMBER INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $
$
OCCUR
CLAIMS-MADE DED RETENTION $
PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $
EACH OCCURRENCE $ DAMAGE TO RENTED
PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
7/19/2022
USI Insurance Services NW
601 Union Street, Suite 1000
Seattle, WA 98101 206-441-6300
Everest National Insurance Company 10120
A SI8ML02071-221 1/1/2022 1/1/2023 1,000,000
1.000.000
✓
5,000
✓
1,000,000
✓ Participant Liability
5,000,000
3,000,000
Participant Liability 1,000,000
A SI8ML02071-221 1/1/2022 1/1/2023 1,000,000
✓ ✓
A SI8EX01297-221 1/1/2022 1/1/2023 1,000,000
✓ 1,000,000
A Sexual Abuse & Molestation SI8ML02071-221 1/1/2022 1/1/2023 Gary Patterson
$1,000,000
$2,000,000
Any One Occ
Aggregate
California State Soccer Association South
US Adult Soccer Association, Inc.
Its Member National Affiliates, Leagues & Teams
7000 S. Harlem Ave
Bridgeview IL 60455
69308754
✓ ✓
✓
✓
City of Redondo Beach, its officers, elected and appointed officials, employees, and volunteers are named additional insured. its Member National Affiliates, Leagues or Member Teams.
South Bay Sports, LLC
City of Redondo Beach
415 Diamond Street
Redondo Beach CA 90277
California State Soccer Association South, , 1029 S. Placentia Avenue Fullerton, CA 92831 Certificate Holder is Additional Insured as pertains to sanctioned games/practices of the named insured The effective date of coverage for the Affiliates, Leagues & Teams shown is the date they were accepted as a member of USASA. 69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 1 of 6 ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:
LOC #:
AGENCY
CARRIER NAIC CODE
POLICY NUMBER
NAMED INSURED
EFFECTIVE DATE:
Primary Non-Contributory and Waiver of Subrogation apply per forms attached.
USI Insurance Services, LLC California State Soccer Association South US Adult Soccer Association, Inc.
Its Member National Affiliates, Leagues & Teams
7000 S. Harlem Ave
Bridgeview IL 60455
25 ACORD 25 (03/16)
ADDENDUM/DOO
HOLDER:
ADDRESS:
City of Redondo Beach
415 Diamond Street Redondo Beach CA 90277
69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 2 of 6
COMMERCIAL GENERAL LIABILITY
ECG 04 704 11 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ECG 04 704 11 13 Copyright, Everest Reinsurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc. used with its permission.
GENERAL LIABILITY ENHANCEMENT ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverage, please refer to policy language in this endorsement and the underlying Commercial General Liability Coverage Form.
Coverage Applicable Enhancement
Non-Owned Watercraft Less Than 50 Feet
Supplementary Payments – Bail Bonds $1,000
Supplementary Payments – Loss Of Earnings $500 per day
Newly Acquired Organizations – Extended Coverage 180 days Subsidiaries As Insureds Included
Fire Damage To Premises Rented To You $500,000
Notice To Company – Duties In The Event Of Occurrence, Claim Or Suit Broadened
Unintentional Failure To Disclose Hazards Broadened
Waiver Of Subrogation Broadened
Amendment to Bodily Injury Definition Broadened
A. Non-Owned Watercraft
Paragraph g.(2) under Paragraph 2. Exclusions
of Section I – Coverage A Bodily Injury And
Property Damage Liability is replaced by the following:
(2) A watercraft you do not own that is:
(a) Less than 50 feet long; and
(b) Not being used to carry persons or property
for a charge;
B. Supplementary Payments – Increased Limits
Paragraphs 1.b. and 1.d. under Supplementary
Payments – Coverages A And B of Section I –
Coverages are replaced by the following:
b. Up to $1000 for cost of bail bonds required
because of accidents or traffic law violations
arising out of the use of any vehicle to which
the Bodily Injury Liability Coverage applies. We
do not have to furnish these bonds.
d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work.
C. Newly Acquired Organizations – Extended
Coverage
Paragraph 3.a. under Section II – Who Is An Insured is replaced by the following:
a. Coverage under this provision is afforded only
until the 180th day after you acquire or form
the organization or the end of the policy period,
whichever is earlier;
D. Subsidiaries As Insureds
The following is added to Section II – Who Is An
Insured:
4. Any subsidiary company in which you own a
financial interest of more than 50% as of the effective date of this endorsement is included as a Named Insured. However, such organization
is not a Named Insured:
a. If it is a partnership, joint venture or limited
liability company;
b. If there is other similar insurance available
to it;
INSURED COPY
7/19/2022 US Adult Soccer Association, Inc.
SI8ML02071-221
California State Soccer Association South
69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 3 of 6
Includes copyrighted material of Insurance Services Office, Inc. used with its permission.
ECG 04 704 11 13
c. If there is other similar insurance that would
be available to it, but for the termination of
the insurance or the exhaustion of its limits
of insurance; or
d. After you cease to own a financial interest
of more than 50%.
E. Fire Damage To Premises Rented To You –
Increased Limits
Paragraph 6. under Section III – Limits of Insurance is replaced by the following:
6. Subject to Paragraph 5. above, the most we
will pay under Coverage A for damages because of “property damage” to any one premises while rented to you or temporarily occupied by you with permission of the owner is the greater of:
a. $500,000; or
b. The Damage To Premises Rented To You
Limit shown in the Declarations.
F.Notice To Company
The following is added to Condition 2. Duties In
The Event Of Occurrence, Offense, Claim Or
Suit under Section IV – Commercial General Liability Conditions:
e. Your failure to first notify us of a claim will not
invalidate coverage under this policy if the loss
was inadvertently reported to another insurer.
However, you must report any such “occurrence” to us within a reasonable time once you become aware of such error.
G. Unintentional Failure To Disclose Hazards
Condition 6. Representations under Section IV –
Commercial General Liability Conditions is replaced by the following:
6. Representations
By accepting this policy, you agree:
a. The statements in the Declarations are
accurate and complete;
b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon
your representations.
Any unintentional error or omission in the description of, or failure to completely describe, any premises or operations you intend to be
covered by this Coverage Part, will not invalidate or affect coverage for those premises or operations. However, you must report any such
error or omission to us as soon as reasonably
possible after its discovery.
H. Waiver Of Subrogation
The following is added to Condition 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV – Commercial General Liability
Conditions:
We waive any right of recovery we may have
against any person or organization because of
payments we make for injury or damage arising
out of your operations or "your work" done under a
written agreement that requires you to waive your
rights of recovery. The written agreement must be
made prior to the date of the “occurrence”.
I. Amendment to Bodily Injury Definition
Paragraph 3. Of Section V. – Definitions is
replaced by the following:
3. “Bodily injury” means bodily injury, sickness,
mental injury, mental anguish, shock or fright
sustained by a person, including death resulting
from any of these at any time. However, “bodily
injury” does not include injury arising out of the
offenses designated in the definition of
“personal and advertising injury”.
69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 4 of 6 INSURED COPY SI8ML02071-221
69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 5 of 6 CG 20 11 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: SI8ML02071211 COMMERCIAL GENERAL LIABILITY CG 20 11 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED – MANAGERS OR
LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
SCHEDULE
Designation Of Premises (Part Leased To You):
Name Of Person(s) Or Organization(s) (Additional Insured):
ANY CERTIFICATE HOLDER IDENTIFIED AS AN ADDITIONAL INSURED ON A
CERTIFICATE ON FILE WITH THE COMPANY
Additional Premium: INCL.
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 you or those acting
on your behalf in connection with the ownership,
maintenance or use of that part of the premises
leased to you and shown in the Schedule and
subject to the following additional exclusions:
This insurance does not apply to:
1. Any "occurrence" which takes place after you
cease to be a tenant in that premises.
2. Structural alterations, new construction or
demolition operations performed by or on
behalf of the person(s) or organization(s)
shown in the Schedule.
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.
B. 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;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
INSURED COPY
US Adult Soccer Association, Inc.
SI8ML02071-221
City of Redondo Beach Aviation Park
1935 Manhattan Beach Blvd
Redondo Beach CA 90278
City of Redondo Beach
415 Diamond Street
Redondo Beach CA 90277
Its Member National Affiliates, Leagues & Teams
California State Soccer Association South
69308754 | 22/23 Master Certificate | Raul Aguayo | 7/19/2022 10:21:16 AM (PDT) | Page 6 of 6