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_ ACCORD CERTIFICATE OF LIABILITY INSURANCE * 12/29/2025
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THIS CERTIFICATE 1S 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 hoider 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 te the certificate holder in lieu of such andorsementis).
PRODUCER : Souract .
LC #40858248 [PHONEy, 612-345-9683 TERE wor
Player's Health Cover USA Inc. | Fouibas: Certificates
@ playershealth.com
Lifetime Work Edina 200 Southdale Center INSURER(S} AFFORDING GOVERAGE ! NAIC#
Edina MN $5435 INSURERA: Everest National Insurance Company | 10120
weuRED ; ~ msusera: HO! Global Speciaty SE . ,
New York State West Youth Soccer Association
16131
INSURER Cr Great American ingurance Company - t_ 16691
PO Box 1014 . INSURER D: |
INSURER E: -_ |
Webster NY_ 14580 INSURER F H
COVERAGES CERTIFICATE NUMBER: 255195 REVISION NUBIBER: 4
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 SY PAID CLAIMS.
pel _TYPE OF INSURANCE ~ ee "POLICY NUMBER. HABE) : GMDON
TS | Los
OX | COMMERGIALGENERALLIABIITY = |} EACH OCCURRENCE ‘s 1,000,000,
bog i | GAMAGE TO Rt ts 300,000
Poy of H |PREMISES (Fa occurence): & Lbeh
boy : MEDEXP
(Any one parson) 15 EXCLUDED
iy : GCNO012812-251 9/1/2028 | 91/2028 | persona. aapvinuuRY js 1,000,000
io: : igeneraLaccrecare —'g 5,000,000
: : ‘ ‘PRopucTs-compior
ace | 5 1,000,000
: ; : PARTICIPAN
LEGAL T
TAB “7"5 7,000,000
| AUTOMOBILELIABILITY ii | CONEIED
(a eeckdent) SINGLE DIA is~? 4,000,000
| ANY AUTO ' ; | AODILY INJURY (Por person) | §
A |_| autos omy [ ‘AOS | | | @oNoni2e12251 j S7ees |: si/a026 . | BODLYERYWY resco ST
1 {577i NONGu i {
LX Aurosomy 12) AUTOS ONLY fo i : [@eracciien nn eel
' |
| | } if i
| PMMPRELLALIAB OX) occur i : i EACH OGCURRENCE 85,000,000 ]
B |X| sxcesgimn 2 | OLAIMSHMADE! i { 25081303 9/1/2025 + 9/1/2028 | accREGATE is 5,000,000
logo laerentions0 t| i i is
WORKERS COMPENSATION T 4 Hi H PT PER PO POR. |
[AND EMPLOYERS” LIABILITY vinj | ot | | » LLSTAITE.. iBR |
LANYPROPRIETORIPARTNERIEXECUTIVE tat : | E:L EACH ACCIDENT 's
(OFFICERIMEMBER EXCLUDED? [NIA i i ean aan
HMandatory i NH) : & i : | GA. DISEASE
- GA EMPLOYEE: S.
jifyes, deserihe under. i of | i f :
DESCRIPTION OF OPERATIONS below H i i i | E1. DISEASE - POLICY LIMIT +=
t : H {
1 if ; i i
H H
© | Participant Accident Medical i |! BSR-Ra2e842.04 !! af2n28 +: gnizozg |' PERINJURY LIMIT '
| $190,000
=F i
t H Hi H i J i
DESGRIPTION OF OPERAT
/ LOCATIONS
IONS / VEHICLES (ACORD 103, Adit may be if mora spate is required}
Certificate issued for sanctioned activities of the state soccer association.
Certificate Holder is Additional Insured as required by written agreement per palicy endorsement ECG 20 600 05 09. Generat Habifity policy contains sexual
abuse and molestation Jimits of $1,000,000 por eccurrence/$2,000,000 aggregate. This cerlificate is issued on behalf of: Lancaster-Depew Sotcer Club
LDSC Soccer Tournament
CERTIFICATE HOLDER . CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED iN
Town of Aurora ACCORDANCE
WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
575 Oakwood Avanue
East Aurora NY 74052
. ©1988-2015 ACORD CORPORATION. AN rights reserved.
ACORD 26 (2016/03) . The ACORD name and logo are registered marks of ACORD