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PROOF OF INSURANCE (2020 - 2020) CLOSED
'`�`' " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 1 10/15/2019 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). PRODUCER CONTACT Liberty United Insurance Services, Inc PHONE Sam Muradyan FAX 704 S Victory Blvd, Suite 204 (,IC, o Ext) 8187618888 (AIC, No): 8882656889 Burbank, CA 91502 ADDRESS. Sam@libertyunitedinsurance.com License #: OF89841 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Admiral Insurance Company INSURED (INSURER B: Elite Special Events, Inc INSURER C; 11278 Los Alamitos Boulevard #101 INSURER D: Los Alamitos, CA 90720 INSURER E:: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-279009 REVISION NUMBER: 245 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 CONTRACTOR 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 INSRR I TYPE OF INSURANCE IANSD SUBIR POLICY EFF POLICY EXP WVD POLICY NUMBER (MMIDDIYYYYI I IMM DDIYYYYI I LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y CA000032316-02 10/28/2019 10/28/2020 EACH OCCURRENCE S 1,000,000 CLAIMS -MADE IA � OCCUR GEN'L AGGREGATE LIMIT APPLIES PER PRO, X IPoLIcv JE::C:117 (.CIE: OTHER: AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE AUTOMOBILE LIABILITY OFFICER/MEMBER EXCLUDED? ANY AUTO (Mandatory in NH) OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED ,,,,,,,,_ AUTOS ONLY „,.........,„ AUTOS ONLY UMBRELLA LIAB OCCUR EXCESS LIAB �I CLAIMS -MADE IDED N I RETENTIONS 300,000 WORKERS COMPENSATION 5,,000 AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y I N OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DAMAGE RENTED PREMISESa occurrence) $ 300,000 MED EXP (Any one person) S 5,,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG S 2,000,000 C01"I NED StlNGLE', LIIM I"(' S raga timd'am) BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE S (Per accident) EACH OCCURRENCE AGGREGATE PER OTH- .,,.. STATUTE ER E L EACH SIDENT S EASE -EA EMPLOYEE S E L DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo, its officers, officials, employees and volunteers are listed as additional insureds W/ CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on October 15, 2019 at 12:02PM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE "_ (SMS) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on October 15, 2019 at 12:02PM Policy Number: CA000032316-02 CG 20 26 04 13 Effective Date: 10/28/2019 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of EI Segundo, its officers, officials, employees and volunteers 350 Main Street EI Segundo, CA 90245 U Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11— Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those act- ing on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is re- quired by a contract or agreement, the insurance af- forded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these addi- tional insureds, the following is added to Section Ill — Limits Of Insurance: If coverage provided to the additional insured is re- quired by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of in- surance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Lim- its of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 13 ,�C" ' 10//040412201CERTIFICATE OF LIABILITY INSURANCE ( DATE /, 019 Y) 9,,,,,,,,,,,,,, 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 pollcy(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). PRODUCER NAM '' l.0 Dave Warren GONIACI Nielsen McAnany Insurance Services, Inc I lt,N. 0f)'(.)'0 379-8801 I I' " (805) 204-4501 Noi 4165 E Thousand Oaks Blvd I'MAR Suite 325 INSURE R(S) AFFORDING COVERAGE NAIC R Westlake Village CA 91362 INSURERA: California Auto Insurance 38342 INSURED INSURER B ELITE SPECIAL EVENTS, INC INSURER C 404 N Sparks St I INSURER D INSURER E Burbank CA 91506-1963 INSURER F COVIERAGES CERTIFICATE NUMBER: CL1910406476 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 d'a u'.Ihll.^,,^ill nlh PULICV'Eri- f POLICYEXP LIMITS LTR TYPE OF INSURANCE INSO WVn POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYj COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE IS DAMAGL IO HENIED CLAIMS -MADE OCCUR PREMISE_, 'Fa orc'.irmnce) s I�I MED EXP (Am one person) II $ UIII PERSONAL & ADV INJURY { s GEN'LAGGREGATE LIMIT APPLIES PER: a GENERAL AGGREGATE I� $ POLICY JECT LOC PRODUCTS - COMP/OP AGG U S OfIlk°,R ( I $ AUTOMOBILE LIABILITY I COJ1Ad'I`0 P "NAI G5 E tt limtt Is 1,000,000 ANYAUTO ( BODILY INJURY (Per person) s A OWNED+fir SCHEDULED BA040000023533 08/31/2019 08/31/2020 I BODILY INJURY (Per accident) s AUTOS ONLY AUTOS HIRED NON -OWNED P C.J �PIGt : R I Y DAMAs AUTOS ONLY AUTOS ONLY I If ird +irt.ritkt""r'It is UMBRELLA LAB OCCUR U EACH OCCURRENCE s EXCESS LAB II CLAIMS -MADE AGGREGATE S DED f u RETENTION sIIII YY s WORKERS COMPENSATION V STA LITE FRH AND EMPLOYERS' LIABILITY Y r N ANY PROP RI ETD R/PA RTN ER/EXECUTIVE N/A EL EACH ACCIDENT s OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo, its officers, officials, employees, and volunteers are additional insured per attached MCA85100817 10 days notice of cancellation for non-payment of premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 J. McAnany © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (__) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of EI Segundo, Policy No. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # ( I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pro�vis yrs or the agreern, 1, iadfl Automatically become void. Signature of Applicant Date ✓ r" Print Name Agreement for: A Dated; Reviewed b S�eilti� .6,ien�s -1 p5 5�/,V7 , , /I -kms