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HomeMy WebLinkAboutCOI - Skyhawks Sports Academy - Expires 2023-06-10ANY 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 SOUT888 OP ID: WK 01/17/2023 RPS Bollinger Sports & Leisure PO Box 1322 Morristown, NJ 07960 Will Krouslis *Markel Insurance Company South Bay Youth SportsDBA Skyhawks SportsAcademy593 King George Ave.San Jose, CA 95136 A X 1,000,000 X X 3602AH013344-0 06/10/2022 06/10/2023 100,000 X 5,000 X 1,000,000 3,000,000 X 1,000,000 1,000,000A 3602AH013344-0 06/10/2022 06/10/2023 XX A 4102AH013343-0 06/10/2022 06/10/2023 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. GILROY9 City of Gilroy, its officers, officials and employees 7351 Rosanna Street Gilroy, CA 95020 38970 $1,000,000/$2,000,000 Incl Particpants Sex Abuse Accident Insurance DocuSign Envelope ID: F2EB33DA-CC82-4579-83D3-CE737C59E778DocuSign Envelope ID: ED0BD936-4721-49CE-BEBA-7F63C991FB36 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date:06/15/22 Policy Expiration Date:06/08/23 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number:76 WEG AS8ZX3 Endorsement Number:1 Effective Date:06/17/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:South Bay Youth Sports LLC 593 KING GEORGE AVE SAN JOSE CA 95136 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. SCHEDULE Person or Organization Job Description Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from us DocuSign Envelope ID: F2EB33DA-CC82-4579-83D3-CE737C59E778DocuSign Envelope ID: ED0BD936-4721-49CE-BEBA-7F63C991FB36 WLTR005 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 January 23, 2023 South Bay Youth Sports LLC 593 KING GEORGE AVE SAN JOSE CA 95136-3736 Account Information: Policy Holder Details :South Bay Youth Sports LLC Contact Us Need Help? Chat online or call us at (866) 467-8730. We're here Monday - Friday. Enclosed please find a Summary Of Insurance for the above referenced Policyholder.Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team DocuSign Envelope ID: F2EB33DA-CC82-4579-83D3-CE737C59E778DocuSign Envelope ID: ED0BD936-4721-49CE-BEBA-7F63C991FB36 Sum of Insurance January 23, 2023 Account Policy Information: Agency Name AUTOMATIC DATA PROCESSING INS AGCY Agency Code 76250871 Recipient Information South Bay Youth Sports LLC 593 KING GEORGE AVE SAN JOSE CA 95136-3736 SUMMARY OF INSURANCE Account Policy Recap Policy Number Policy Term Premium Worker’s Compensation Twin City Fire Insurance Company 76 WEG AS8ZX3 06/08/2022 to 06/08/2023 $8,106 DocuSign Envelope ID: F2EB33DA-CC82-4579-83D3-CE737C59E778DocuSign Envelope ID: ED0BD936-4721-49CE-BEBA-7F63C991FB36 Summary of Insurance (Continued) Sum of Insurance Worker’s Compensation Summary of Insurance with Twin City Fire Insurance Company A member company of The Hartford 06/08/2022 - 06/08/2023 Policy Detail:Worker’s Compensation Policy States:CA Location 1 Premises Address: 593 King George Ave San Jose CA 95136 Worker’s Compensation Coverages: Employer’s Liability Limits Limit Disease - Policy Limit $1,000,000 Bodily Injury – Accident $1,000,000 Disease - Each Employee $1,000,000 Class/Payroll Detail Class Description Class Code Payroll Location 1 - CA HEALTH CLUBS OR GYMS - INCLUDING RESTAURANT EMPLOYEES, RETAIL STORE EMPLOYEES AND RECEPTIONISTS 9053 $261,800 This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions, limitations or exclusions. Please refer to the actual policy forms for detailed coverages, limits and deductibles. DocuSign Envelope ID: F2EB33DA-CC82-4579-83D3-CE737C59E778DocuSign Envelope ID: ED0BD936-4721-49CE-BEBA-7F63C991FB36