ACORD 25 (2016/03)
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© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
09/23/2023
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 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).
PRODUCER CONTACT NAME: Mass Merchandising Underwriting
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne, IN 46804
PHONE
(A/C, No, Ext): 1-800-426-2889 FAX
(A/C, No): 1-260-459-5105
E-MAIL
ADDRESS: [email protected]
PRODUCER
CUSTOMER ID:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Peacemakers Inc
110 Schooner Ct
Richmond, CA 94804
A Member of the Sports, Leisure & Entertainment RPG
INSURER B:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: U00048432 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
LTR TYPE OF INSURANCE ADDL
INSD
SUBR
WVD POLICY NUMBER POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007893500 09/27/2023 12:01 AM EDT
09/27/2024
12:01 AM
EACH OCCURRENCE $1,000,000
CLAIMS-
MADE X OCCUR DAMAGE TO RENTED
PREMISES (Ea Occurrence) $1,000,000
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $5,000,000
GEN’L AGGREGATE LIMIT APPLIES PER: PRODUCTS – COMP/OP AGG $1,000,000 POLICY
PRO-
JECT LOC PROFESSIONAL LIABILITY $1,000,000
OTHER: Legal Liability to Participants $1,000,000
A AUTOMOBILE LIABILITY 6BRPG0000007893500 09/27/2023
12:01 AM EDT
09/27/2024
12:01 AM
COMBINED SINGLE LIMIT
(Ea accident) $1,000,000
ANY AUTO BODILY INJURY (Per person)
OWNED AUTOS
ONLY
SCHEDULED
AUTOS BODILY INJURY (Per accident)
X HIRED
AUTOS ONLY X NON-OWNED
AUTOS ONLY
PROPERTY DAMAGE
(Per accident)
X Not provided while in Hawaii.HAWAII
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
ANY PROPRIETOR/PARTNER/
EXECUTIVE OFFICER/MEMBER
EXCLUDED? (Mandatory in NH)
If yes, describe under DESCRIPTION
OF OPERATIONS below
N/A PER
STATUTE OTHER
Y / N E.L. EACH ACCIDENT
E.L. DISEASE – EA EMPLOYEE
E.L. DISEASE – POLICY LIMIT
A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007893500 09/27/2023 12:01 AM EDT
09/27/2024
12:01 AM
PRIMARY MEDICAL
EXCESS MEDICAL $25,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Legal Liability to Participants (LLP) limit is a per occurrence limit.
Sport(s): Youth Football (Tackle & Contact) Age(s): 12 & Under, 13-15 Sexual Abuse Liability - $1,000,000 aggregate (included above) / $250,000 each occurrence (included above) The Certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured.
CERTIFICATE HOLDER CANCELLATION
City of San Pablo
1000 Gateway Blvd
San Pablo, CA 94806
Owner/Manager/Lessor of Premises
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
Coverage is only extended to U.S. events and activities. ** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas
CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1
c
POLICY NUMBER: 6BRPG0000007893500 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED – DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s) City of San Pablo
1000 Gateway Blvd
San Pablo, CA 94806
Named Insured: Peacemakers Inc
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 your acts or omissions or the acts or omissions of those
acting on your behalf:
1. In the performance of your ongoing operations; or
2. In connection with your premises owned by or
rented to you.
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
shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.