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HomeMy WebLinkAbout2012-13 Tiburon Peninsula Soccer LeagueACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 8/17/2012 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 1 1 F P /C No Ext)*973-467-8005 A 0 J K arkway E-MAIL Short Hills NJ 07078 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Natl U Fire Ins Co Pttsbrgh PA 19445 INSURED INSURER B :Phil d I is Indemnity Ins Co 18058 U.S. Club Soccer INSURER C : 716 8th Avenue North l INSURER D : Myrt e Beach SC 29577 INSURER E INSURER F GUVtKAUI=5 CERTIFICATE NUMBER: 712R1 9A1 F 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 INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS B GENERAL LIABILITY Y HPK803496 1/1/2012 /1/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $300,000 X] CLAIMS-MADE OCCUR MED EXP (Any one person) $Excluded X Inc. Part. Liab. PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 7 POLICY F] JECT PRO X LOC Abuse/Molestation $1,000,000 AUT OMOBILE LIABILITY N LIMIT Ea accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE Per accident $ B UMBRELLA LIAB X OCCUR PHUB366907 1/1/2012 /1/2013 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DIED X RETENTION $10,000 $ WORKERS COMPENSATION WC STATU OTH- AND EMPLOYERS' LIABILITY TORY LIMIJS ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ FFICER/ N/A E.L. EACH ACCIDENT $ O MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Accident Insurance RG9132928 1/112012 /1/2013 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 US CLUB SOCCER VALID PASSCARD HOLDERS PARTICIPATING AND PLAYING IN Tiburon Peninsula Soccer Club, Club ID #4881 for tournament: Tiburon/Mill Valley Fall Kickoff, August 25-26, 2012 Group Code: Club #4881 CERTIFICATE HOLDER CANCELLATION Town of Tiburon 1505 Tiburon Blvd Tiburon CA 94920 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 ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC'oR°0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) L 5 /1/2012 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 endorsements . PRODUCER CONTACT NAME: Bollinger Insurance 101 JFK P PHONE - 7- A/C No):973-921-2876 arkway E-MAIL Short Hills NJ 07078 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A :Philadelphia Indemnity Ins Co 18058 INSURED INSURER B : California Youth Soccer INSURER C : 1040 Serpentine L Suite 201 , Pl INSURER D : easanton CA 94566 INSURER E : INSURER F : COVERAGES i RFVISInN NIIMRFR- THIS IS TO C ERTIFY 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 INSR UBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY PHPK754532 /1/2011 /1/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 7 CLAIMS-MADE 1~7 OCCUR MED EXP (Any one person) $5,000 X Ind Part Lia 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 LOC Sexual Abuse & Moles $1 MIL/$2MIL A AUT OMOBILE LIABILITY PKPK754532 /1/2011 /1/2013 Ea accidennt 1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X X NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- I AND EMPLOYERS' LIABILITY TORY LIM T, Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER E N/A E.L. EACH ACCIDENT $ XCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) All operations of CYSA North, its youth member teams, & leagues. The certificate holder is named as an additional insured with respects to the liability coverage. THIS CERTIFICATES IS VALID ONLY FOR CYSA NORTH SANCTIONED EVENTS/ACTIVITIES. Certificate is issued on behalf of TIBURON PENINSULA SOCCER CLUB CERTIFICATE NUMBER: 1 7nQa7oaQ Group Code: 5-06 cFRTIFICATF Hni IIFR renirPI I ATlnKI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF TIBURON ACCORDANCE WITH THE POLICY PROVISIONS. 1505 TIBURON BLVD. TIBURON CA 94920 AUTH RIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD COVERAGES CERTIFICATE NUMBER: FFi naaaRn 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. INTR R TYPE OF INSURANCE NADDL SR SUBR WVD POLICY NUMBER MM/ DYIYYEFF YY POLICY EX MM/ D/YYYY LIMITS B GENERAL LIABILITY Y PHPK803496 1/1/2012 /1/2013 EACH OCCURRENCE $1,000,000 IX COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $300,000 1 CLAIMS-MADE 15F] OCCUR MED EXP (Any one person) $Excluded X Inc. Part. Liab. PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICY F7 jECT PRO X LOC Abuse/Molestation $1,000,000 AUT OMOBILE LIABILITY SINGLE COMBINED LI Ea accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident B UMBRELLA LIAB X OCCUR PHUB366907 /1/2012 /1/2013 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION $10,000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY T Y ANY PROPRIETOR/PARTNER/EXECUTIVE /N ❑ NIA E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Accident Insurance RG9132928 1/1/2012 /1/2013 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 US CLUB SOCCER VALID PASSCARD HOLDERS PARTICIPATING AND PLAYING IN Tiburon Peninsula Soccer Club, Club ID #4881 Group Code: Club #4881 CERTIFICATE HOLDER CANCELLATION Town of Tiburon 1505 Tiburon Blvd Tiburon CA 94920 REVISION NUMBER- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THORIZED REPRESENTATIVE AC°RL> CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/17/2012 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 endorsements . PRODUCER CONTACT NAME: Bollinger Insurance PHONE E.t):973-467-8005 AFAX /C No 101 JFK Parkway E-MAIL Short Hills NJ 07078 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A INSURED INSURER B : hil I hl Indemnity Ins Co 18058 U.S. Club Soccer INSURER C : 716 8th Avenue North INSURER D : Myrtle Beach SC 29577 INSURER E : INSURER F : ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK754532 COMMERCIAL GENERAL LIABILITY 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. Name of Person or Organization: TOWN OF TIBURON 1505 TIBURON BLVD. TIBURON CA 94920 SCHEDULE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1