The URL can be used to link to this page

COI - Youth Evolution Basketball - Expires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ity of Burbank 275 E Olive Ave Burbank, CA 91502 City of Burbank 275 E Olive Ave Burbank, CA 91502 City of San Luis Obispo 1341 Nipomo St. San Luis Obispo CA, 93401 4102AH011243-33602AH011244-4 City of GilroyRecreation Department 7351 Rosanna St. Gilroy, CA 95020 DocuSign Envelope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ocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD YOUTH97 OP ID: WK 09/08/2023 RPS Bollinger Sports & Leisure PO Box 1322 Morristown, NJ 07960 Will Krouslis *Markel Insurance Company Youth Evolution Activities3377 Driftwood Rd.Santa Maria, CA 93455 A X 1,000,000 X XX3602AH011244-4 09/01/2023 09/01/2024 100,000 X 5,000 1,000,000 3,000,000 X 1,000,000 1,000,000A 3602AH011244-4 09/01/2023 09/01/2024 XX A 4102AH011243-4 09/01/2023 09/01/2024 Med Max 25,000 Full Excess Ded 250 Certificate holder is included as an additional insured. Coverage is provided under these policies only for sponsored/supervised activities of the named insured for which a premium has been paid. SANTAC8 38970 Incl Particpants Accident Insurance City of Gilroy Recreation Department 7351 Rosanna St. Gilroy, CA 95020 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 This endorsement modifies insurance provided under the following: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008CG 24 04 05 09 COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE POLICY NUMBER: Page 1 of 1 The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Sec- tion IV- Conditions: Name Of Person Or Organization: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. We waive any right of recovery we may have against the person or organization shown in the Schedule above 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 organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. 3602AH011244-1 City of Burbank 275 E Olive Ave Burbank, CA 91502 WHERE ARE YOU REQUIRED BY WRITTEN CONTRACT TO OBTAIN THIS AGREEMENT FROM US, PROVIDED THE CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF LOSS TO WHICH THIS WAVIER APPLIES. IN NO INSTANCE SHALL THE PROVISIONS AFFORDED BY THIS ENDORSEMENT BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE 3602AH011244-4 City of Gilroy Recreation Department 7351 Rosanna St. Gilroy, CA 95020 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION Copyright, Insurance Services Office, Inc., 2012CG 20 01 04 13 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 (2) POLICY NUMBER: You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy pro- vided that: (1)The additional insured is a Named Insured under such other insurance; and The following is added to the Other Insurance Con- dition and supersedes any provision to the con- trary: Page 1 of 1 3602AH011244-14102AH011243-33602AH011244-4 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ABUSE,MOLESTATION,OR EXPLOITATION COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is added to Section I -Coverages: COMMERCIAL GENERAL LIABILITY Employment,investigation,supervision,retention,or training of any person for whom the insured is or ever was legally responsible;or (a) A. Insuring Agreement No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments -Coverages A,B,And Abuse,Molestation,Or Exploitation Cover- age. 1. We will pay those sums the insured becomes legally obligated to pay as damages because of "bodily injury","property damage",or "personal and advertising injury"arising out of abuse,molestation,or exploitation,including but not limited to physical or sexual abuse,molestation,or exploitation,to which this insurance applies.We will have the right and duty to defend the insured against any "suit"seeking such damages.However,we will have no duty to defend the insured against any "suit"seeking damages to which this insurance does not apply.Nor do we have a duty to defend any insured who is alleged to have taken part in the abuse,molestation,or exploitation.We may,at our discretion,investigate and settle any claim or "suit"that may result.But: a. Page 1 of 4IncludescopyrightedmaterialofInsuranceServicesOffice,Inc., with its permission. MGL 1262 10 19 POLICY NUMBER: $Aggregate SCHEDULE Abuse,Molestation,Or Exploitation Limits Of Insurance $Each Person The amount we will pay for damages is limited as described in Paragraph C.Limits Of Insurance be- low;and (1) Reporting or failing to report the abuse,molestation,or exploitation to the proper authorities;and(b) ABUSE,MOLESTATION,OR EXPLOITATION COVERAGE Our right and duty to defend ends when we have used up the applicable limit of insurance in the pay- ment of judgments or settlements under this Abuse,Molestation,Or Exploitation Coverage. (2) This insurance applies to "bodily injury","property damage",or "personal and advertising injury"arising out of abuse,molestation,or exploitation only if the abuse,molestation,or exploitation: b. Takes place in the "coverage territory";(1) Results from the insured’s negligence in:(2) First occurs during the policy period.(3) Abuse,molestation,or exploitation of any one persone which first occurs during the policy period includes any continuation,change,or resumption of that abuse,molestation,or exploitation of that person after the end of the policy period. c. Multiple acts of abuse,molestation,or exploitation of any one person by one or more perpetrators will be deemed to have first occurred at the time of the first act of such abuse,molestation,or exploitation. d. 1,000,000 2,000,000 3602AH011244 -1 Markel Insurance Company 4102AH011243-33602AH011244-4 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 Exclusions2. Breach Of Contracta. This insurance does not apply to: "Bodily injury","property damage",or "personal and advertising injury"arising out of a breach of contract. Contractual Liabilityb. "Bodily injury","property damage",or "personal and advertising injury"for which the insured has assumed liability in a contract or agreement.This exclusion does not apply to liability for damages that the insured would have in the absence of the contract or agreement. Criminal Investigation,Prosecution,Or Proceedingc. Any criminal investigation,prosecution,or proceeding. Employer’s Liabilityd. "Bodily injury"or "personal and advertising injury"to: An "employee"of the insured arising out of and in the course of:(1) Performing duties related to the conduct of the insured’s business;or(b) The spouse,child,parent,brother,or sister of that "employee"as a consequence of Paragraph (1) above. Employment by the insured;or(a) (2) Expected Or Intended Injurye. This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury. "Bodily injury"or "property damage"expected or intended from the standpoint of the insured. Fines And Penaltiesf. Any fines,penalties,punitive damages,exemplary damages,multiplied damages,statutory damages,or aggravated damages. Knowing Violation Of Rights Of Anotherg. "Personal and advertising injury"caused by or at the direction of the insured with the knowledge that the act would violate the rights of another and would inflict "personal and advertising injury". Material Published With Knowledge Of Falsityh. "Personal and advertising injury"arising out of oral or written publication,in any manner,of material,if done by or at the direction of the insured with knowledge of its falsity. Participating Insuredi. Any insured who takes part or is alleged to have taken part in the abuse,molestation,or exploitation. Passive Insuredj. Any insured listed under Paragraph 1.of Section II -Who Is An Insured who remains "passive"upon gaining knowledge of any actual,alleged,or threatened abuse,molestation,or exploitation.For the purpose of this exclusion,"passive"means the person failed to: Page 2 of 4IncludescopyrightedmaterialofInsuranceServicesOffice,Inc., with its permission. MGL 1262 10 19 Report the actual,alleged,or threatened abuse,molestation,or exploitation to the proper authorities;or(1) Investigate or otherwise take appropriate action in response to knowledge of the actual,alleged,or threatened abuse,molestation,or exploitation,if such investigation or action was within the scope of his or her employment. (2) Previously Initiated Actsk. Any claim or "suit"arising out of abuse,molestation,or exploitation of any one person that began prior to the policy period,even if such claim or "suit"alleges abuse,molestation,or exploitation of such person that continues or resumes during the policy period.In a claim or "suit"alleging abuse of a person by multiple perpetrators,this exclusion applies even if abuse by one or more perpetrators occurred prior to the policy period and abuse by another perpetrator began during the policy period. DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 With respect only to the coverage provided by this endorsement,Section III -Limits Of Insurance is replaced by the following: C. SECTION III -LIMITS OF INSURANCE The Limits Of Insurance shown in the Schedule of this endorsement and the rules below fix the most we will pay under this Abuse,Molestation,Or Exploitation Coverage for covered damages arising out of or in any way related to abuse,molestation,or exploitation,regardless of the number of: 1. Insureds;a. Claims made or "suits"brought;orb. Persons or organizations making claims or bringing "suits".c. The Aggregate limit shown in the Schedule of this endorsement is the most we will pay under Abuse,Moles- tation,Or Exploitation Coverage for the sum of all covered damages arising out of or in any way related to abuse,molestation,or exploitation under the policy. 2. Subject to Paragraph 2.above,the Each Person limit shown in the Schedule of this endorsement is the most we will pay under Abuse,Molestation,Or Exploitation Coverage for covered damages arising out of or in any way related to abuse,molestation,or exploitation committed upon any one person,regardless of the number of acts of abuse,molestation,or exploitation committed,the period of time over which such acts occur,or the number of perpetrators taking part in the abuse,molestation,or exploitation. 3. The coverage provided by this endorsement is the only coverage provided under the policy for liability or damages arising out of or in any way related to abuse,molestation,or exploitation.No coverage is provided for liability or damages arising out of or in any way related to abuse,molestation,or exploitation under any other in- suring agreement or coverage part in the policy. 4. The limits of insurance provided by this endorsement are in addition to,not part of,the limits of insurance provided by the Commercial General Liability Coverage Form. 5. The Limits Of Insurance shown in the Schedule of this endorsement apply separately to each consecutive annual period and to any remaining period of less than 12 months,starting with the beginning of the policy period shown in the Declarations of the Commercial General Liability Coverage Form,unless the policy period is extended after is- suance for an additional period of less than 12 months.In that case,the additional period will be deemed part of the last preceding period for purposes of determining the limits of insurance. Page 3 of 4IncludescopyrightedmaterialofInsuranceServicesOffice,Inc., with its permission. MGL 1262 10 19 Warl. ."Bodily injury","property damage",or "personal and advertising injury",however caused,arising,directly or indirectly,out of: War,including undeclared or civil war;(1) Warlike action by a military force,including action in hindering or defending against an actual or ex- pected attack,by any government,sovereign,or other authority using military personnel or other a- gents;or (2) Insurrection,rebellion,revolution,usurped power,or action taken by governmental authority in hinder- ing or defending against any of these. (3) Workers’Compensation And Similar Lawsm. Any obligation of the insured under a workers’compensation,disability benefits or unemployment compen- sation law,or any similar law. With respect only to the coverage provided by this endorsement,the heading for Supplementary Payments -Cov- erages A And B under Section I -Coverages is amended to read Supplementary Payments -Coverages A,B,And Abuse,Molestation,Or Exploitation Coverage. B. With respect only to the coverage provided by this endorsement,Section IV -Commercial General Liability Condi- tions is amended as follows: D. The heading and Paragraph a.of Condition 2.is replaced by the following:1. Duties In The Event Of Abuse,Molestation,Exploitation,Claim,Or Suit2. You must see to it that we are notified as soon as practicable of an act or allegation of abuse,molesta- tion,or exploitation which may result in a claim.To the extent possible,notice should include: a. A description of the actual or alleged abuse,molestation,or exploitation,including all relevant dates; (1) DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 The names and addresses of all persons involved in the actual or alleged abuse,molestation,or exploitation,including the alleged perpetrators,potential claimants,and witnesses; (2) Particulars as to the reasons for anticipating a claim which may result from such actual or alleged abuse,molestation,or exploitation; (3) The following is added to Paragraph b.Excess Insurance of Condition 4.Other Insurance:2. The insurance provided by this endorsement is excess over any other insurance provided to any insured, whether such other insurance is provided on a primary,excess,contingent,or any other basis,unless such oth- er insurance is written to be specifically excess of this insurance. The nature of the alleged or potential damages arising from such actual or alleged abuse,moles- tation,or exploitation;and (4) The circumstances by which the insured first became aware of the actual or alleged abuse,moles- tation,or exploitation. (5) The following condition is added:3. Multiple Coverage Forms,Insuring Agreements,Or Policies Issued By Us When two or more Coverage Forms,insuring agreements,or policies issued by us or any company affiliated with us apply to the same claim or "suit",the maximum limit of insurance under all such Coverage Forms, insuring agreements,or policies combined shall not exceed the highest applicable limit of insurance under any one Coverage Form,insuring agreement,or policy. With respect only to the coverage provided by this endorsement,Definition 3."bodily injury"under Section V - Definitions is replaced by the following: E. "Bodily injury"means bodily injury,sickness,disease,mental anguish,or emotional distress sustained by a per- son,including death resulting from any of these at any time. 3. All other terms and conditions remain unchanged. Page 4 of 4IncludescopyrightedmaterialofInsuranceServicesOffice,Inc., with its permission. MGL 1262 10 19 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) Schedule Person or Organization Job Description Any person or organization as required by written contract. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 11/8/2021 Policy No.QWC1178517 Endorsement No.0 Insured Rosas, Isaac (An Individual)Premium $584 Insurance Company Sequoia Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84) WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO OBTAIN THIS AGREEMENT FROM US, PROVIDED THE CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF LOSS TO WHICH THIS WAVIER APPLIES. IN NO INSTANCE SHALL THE PROVISIONS AFFORDED BY THIS ENDORSEMENT BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE. QWC117851711/8/22 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5 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-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL 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 AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED 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 EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR 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 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. AmTrust Financial Services Santa Maria Bryan O'Connell YA 1,000,000 Youth evolution basketball 1,000,000 68102-1656 CA QWC1178517 15954 11/08/2021 Huckleberry Insurance Services, LLC 11/08/2022 NEOmaha 12/20/2021 certificate@huckleberry.com 3377 Driftwood Drive 222 S 15th St Ste 1500N 93455 (855) 255-4825 1,000,000 C/O Collections Y Bryan O'Connell 09/8/23 QWC1242507 11/08/22 11/08/23 City of Gilroy Recreation Department 7351 Rosanna St. Gilroy, CA 95020 DocuSign Envelope ID: E87C85D9-BDC7-405E-8042-00361F2226E5