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HomeMy WebLinkAbout2011 Tiburon Peninsula Soccer ClubA C'C>R6r CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/13/2011 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 NAME: Bollinger Insurance PHONE FAX 101 JFK Parkway A/C No Ext : 971 - - P005 A/C, No : 7-1 - 921 - 2 876 Short Hills NJ 07078 E-MAIL ADDRESS: PRODUCER CUSTOMER ID INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Philadelphia Insurance Company 23850 U.S. Club Soccer 716 8th Avenue North INSURERB:Nat1% U Fire Ins Co Pttsbr h PA 19445 Myrtle Beach SC 29577 INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 11 s s 1141 7 c; REVISION Nt]MRFR 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 IN SUB WVD POLICY NUMBER POLICY EFF MM/DD/YYW POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY y PHPK663255 1/1/2011 1/1/2012 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE RENTED PREMISES Ea occurrence $300,000 CLAIMS-MADE a OCCUR MED EXP (Any one person) $Excluded PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2,000,000 POLICY PRO X LOC Abuse/Molestation $$1,000,000 AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY A T (Ea accident) U O ALL OWN BODILY INJURY (Per person) $ ED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ A UMBRELLA LIAB X OCCUR PHUB330300 1/1/2011 1/1/2012 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ X RETENTION $10,000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS I ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT T $ B Accident Insurance SRG9132928 1/1/2011 1/1/2012 Med Max: $100,000 Full Excess Ded: $500 PT Limit: $2,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) The certificate holder is named as an additional insured under the liability policy. This certificate is issued on behalf of all valid US Club Soccer pass card holders participating in Tiburon Peninsula Soccer Club, Club ID #4881 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Tiburon 1505 Tiburon Blvd Tiburon CA 94920 AUTHORIZED REPRESENTATIVE (~I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC AC V ADDITION AL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Bollinger Insurance U.S. Club Soccer 716 8 h A h POLICY NUMBER t venue Nort Myrtle Beach SC 29577 CARRIER NAIC CODE EFFECTIVE DATE: AUUI I IUNAL KtMAKK5 I THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE in Tournament: Tiburon/Mill Valley Fall Kickoff August 27-28, 2011. Group Code: Club #4881 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD