PROOF OF INSURANCE (2020 - 2020) CLOSED1 IY
0 I DATE (MM/DDYYY)
A� ®' CERTIFICATE OF LIABILITY INSURANCE
11/25/2019
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(les) 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 of confer rights to the certificate holder in lieu of such endorsement(s).
PRODU ERrtIflCate BOBS n CONTACT Alexander Yu
INAAI•!!E:,
CoverW
let, Inc.
00 Ave. lof the Americas,E-MAILVVC.t) mcustomer.servi (Ai d tye);
PHONE
EP -PRL ooverwallet.com
ervlce@ .....
Floor 16
INsuRER )AFFORDINGCOVERAGE .. .........................
_I_S
NAIC#
New York, NY. 10013
...INSURER..A......HI scox Ins r nceCompany Inc.
0200
INSURED
INSURER B:
HOT PEPPERS PRODUCTIONS
40170 Stowe Road
INSURER C :
Temecula, CA, 92591
I.RSURERo.?
INSURERE: .............._......,..................,.,.,
,.._.—
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 SAID CLAIMS
INsR 4666
LTR TYPE OF INSURANCE .�i n.
POLICY EFF POLI LIMITS
POLICYNUMBER IMMIDDPYYYY) @M'Md ONYY
X COMMERCIAL GENERAL LIABILITY X
UDC -4335964 -CGL -19 11/20/2019 11/20/2020 EACHOCCURRENCE
$ 1,000,000
u ( X,
.
100,000
CLAIMS -MADE OCCUR
MI
_P. F�G_M�_FS IE'a nccurrars-a, l
$
MED EXP (Any one person)
$ 5,000
PERSONAL INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL
$ 2,000,000
POLICY � JECT F LOC
X...„II
PRODUCTS-COMP/OPAGG
$ 1,000,,000 —
OTHER'.
$
_
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
BODILY INJURY (Per person)
$
OWNED
BODILY U
BOPS INJURY (Per accident)
ROPE N YMAGE
$
AUTOSNLY AUTOS
NON -OWNED
ra� DAMAGE
$
AHIRED UTOS ONLY ONLY
__._.
( P r
$
UMBRELLA LIAB
R,E,N,C,E,
EXCESS LAB CLAIMS -MADE
�I AGGREGATE
$
DED RETENTION $
$
WORKERSCOMPENSATION(
OTH-
ER
AND EMPLOYERS' LIABILITY Y / N
,,,STATUTE,,,,,_....._-_
A NYPROPRI ETOR/PARTN ER/EXECUTI V E
$
OFFICER/MEMBER EXCLUDED? N / A
n NH
ryi)
(Mandatory
E L D SEASE - EA ET E
...$........................... ........ ...--
DESCRIPTION OF OPERATIONS below
E,L, DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
Certificate holder is included as additional insured on a primary non-contributory basis with respect to the General Liability per the policy's terms and conditions.
0
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EI Segundo, CA, 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE �J
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
•
Policy Number:
Named Insured:
Endorsement Number:
Endorsement Effective
UDC -4335964 -CGL -19
HOT PEPPERS PRODUCTIONS
1
November 20, 2019
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II — Who Is An Insured is amended
to include as an additional insured any per-
son(s) or organization(s) for whom you are
performing operations or leasing a premises
when you and such person(s) or organiza-
tion(s) have agreed in writing in a contract or
agreement that such person(s) or organiza-
tion(s) be added as an additional insured on
your policy. Such person or organization is
an additional insured only with respect to lia-
bility 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 acting on your
behalf:
1. In the performance of your ongoing opera-
tions; or
2. In connection with your premises owned by or
rented to you.
A person's or organization's status as an addi-
tional insured under this endorsement ends
when your operations or lease agreement for
that additional insured are completed.
CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its
permission.
Page 1 of 1
PW tw
,tfl 0-1171111 OA
LONAQ.OSON INS.
20,10 LINCOLN BLVD
SANTA MONICA, CA 10405 TELEPHONE.t3101 392.4101
POLICY NU ER POLICY r...IQD
`14,11 04 04`.1114727 Is,„ rra) , ;'11 "01 L1�a o�AMitr+01 f2:1l202012,DIrL1
itnSONS INSU46
NAMED INSt1 0
LOVA L HYA1_T
DRIVERS
LOVA L HYATT
INSURANCE1� "" 4LITOfV10r11L1: POLICY DECLARATIONS
IIV po' RTANT COVERAGE EXCLUSION
APPLICABLE TO ALL COVE' IA(A$, INCLUDING BUT NOT 0MITEO "'IO', LIABILITY
AND UNINBLIl1E0 MI1T'On1vs, P14OVIDED NOW On LA'fw
I'1 Ia otfrnlltl 'Itlnt Ili" 015urnrtoo rlftor led Iry t'ikiq Tsollr,y
Bili Iwnt "Nal)tiv 1mr Imtllrun In Ilrrr ranrrnftl ni Any h6 ewl Of I'my
111Wrrl llwwrty Offli im av'EI"(l airy r"11/01 wil'milo IIr I)OIII11 ,aratarl Dr
0014100 try D P066,l1 liRlorl bolorraglnrsll0'x of Maim Ilam
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.. „�pt�atyl'q r0!rtlrlraal alt, waln�Ilarr,Itsn r;Pl' to. r0",...
CAR ° Y R 12164 B 1 A„ C L It A µAVE a, u." I H. 60 T OR YAWE N SE � P PkC 45 41E H"1w•a; 'pp
ADDRESS I N
"O�L� E „ C ;,INV •flPuu"ut istr llhl aq so 4USCN3246'2LIK5229,'. N 07/2002
11 dr11"a'. CA �0� `ant ,1�""g"�"
2 2000 BMW �
redV'PItSES7 U H C
1 �200� )' U 11!2004
� TI,;:I a O"1�A C�::,IPt"�1•..L..A ,.0 IED �1��1 1 NXBR12E5YZ392227 I
I _. . , ... ' ,WkaNMkAt.4,IS IIA). AA1lEC AD RESEEN d"A) AN rtGIS0ERd0 t.,..wN.._dW*m E89.CTI1LR rn�N T�AP C�D AfrVi
CARLA'PA ia„ kg0,r�w�l TERSTA AW„ bt9MhAYFEANDAfOiTfANI. P ..._.
b
j -
I
ge1Limlts are subject to all policy Coverage applies only if premium charge is listed below. Covera
icy terms.
.._®.,..,. __�. ...
WtEr1A'0S LIMITS'OF;LIgHIL'IT1t' `: PF1M1ritLltil'S
NON VACTOR fg(IUJPMl
CA'122 CARL A ._...
ITEMSof
�EACH DITEM MARE
BODILY INJURY $ 1 00 OOO EACH PERSON S 300,000
EACH ACCIDENT
133 135
FOR STATED
„
G ELIABNLITY EACH ACpOli1T
.—......�.....,.••_•.„,.._... _ ,....
19
TO .
1iERE1N, ITEMS INSURED ARE SUBJECT
lNS OABIUTY
OROPERTYDAMA ......,: _.,
Y $15,000 EACHPERSON $ 30,000
N IPRED 11fVt1T Ila"l �
�, 141OTORdIU�Ty �
BODILY URY UARrSTS $
EACH ACCIDENT
.
17 _
15
SECT
THE DEDUCTIBLE.
PNKWRY MAXIMUM
OPERTECDAMACEUABILITY o
COLLISION DEDUCTIBLE wANER, _ .,,,
MEDICAL EXPENSEI $ p, .., ..... _ „_... __
_ __. _ .�......
_....,
- _ _ ..........,.
CAR
CAR C
LEASEILOAN GAP COVERAGE AR
REPAIR OR REPLACEMENT CAR CAR CAR
COST COV'FRAGE
_ _ _
�50
50 caaz $250
$ 250
CAR $
27 10 _
_
_CALIFORNIA ASSESMENTS
c^mmn.
w �— �
COLLISIONCOMPREW
CAR2 $ 2..-•_
DEDUCTIBLE CARI
R7 $2
CAR $
187 120
7
_ .._ W...
CA FRAU 6
FEE I 1
_
. .. �^.. --
IDE
$75 CAR2 $75
CAR
3
3_...
CIGA FEE
7._
I _� �ASSNS^Ti4NCE
IRFORTgWl"'AERYICES)'"
VOCCURRE;NCECARI
...
LL
RENTAL CAR BENEFIT
p $ PER DAY DAYS
INTFAVENORFFf
ENDoRsENIENTS 1' 1`c11:r0 Y
TTrl01O TH�...—.
,.
P R ........ O
. _"..
406 �
o
U-10 12/2018
......,..�...�._...._., L1CY �EE,
G
TOTAL PREMIUM 896.76']
for Non -Towing IMPORTANT INFORMATION
!'w g Services, Limit of Liability is $75 per Occurrence. Maximum 5 Occurrences in total for
Towing and Non -Towing services per policy period. V
uEFFEC'TIVE 07/29/2019 I
]The enclosed Auto Insurance Renewal Bill and the U251 IMPORTANT NOTICE are part of this policy. These
specify the amount of your premium, your payment options, any applicable fees, and the due date.
Your automobile insurance expires and coverage ceases at 12%01AM on 07/29/2019. Coverage under
this policy will become effective provided you pay the premium and any applicable fees as indicated
on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent or broker at
the phone number provided above.
MAILED TO.
LOVA L HYATT
12104 HAVELOCK AVE
CULVER CITY, CA 90230-5932
U -06-14J208 ..
INSURED COPY
I
I
W
PoN,►Y. NU•MQf;I9; 0401 04 049014727
I�fA1LINS:G�A 0612812019
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 for the 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
g pp
Antonio e provisions
a a8 ,.�,mm�he agreement will automatically become void.
Signature of Applicant cant those provisions^ or the " 09/24/19
immediately comply with
Date
Print Name Antonio Madrictal
AgreementM, ✓
Dated: 1,2 -
Reviewed by:�