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PROOF OF INSURANCE (2020 - 2021) CLOSED'= �DATE � CERTIFICATE OF LIABILITY INSURANCE I 1 01/28/2020 THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. 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 endorsemenl !PRODUCER I C'ONT'ACT NAME: Mass Merchandising Underwriting K&K Insurance Group, Inc. PHONE C E Exti, 800-328-2317 Na); 260-459-5502 1712 Magnavox Way C •MFAX AIL Fort Wayne, IN 46804 ADDRESS: entertainers@kandkilnsurance.com kandkilnsurance.com ICER CUSTOMER IO; INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Nationwide Mutual Insurance Company 23787 SMAX Entertainment I INSURER B: 6836 Magpie Creek Crt. I INSURER C: Las Vegas, NV 89178 A Member of the Sports, Leisure & Entertainment RPG (.INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01671685 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. AODL sutSii OLICY NUMBER ) ILTR TYPE OF INSURANCE (NSD WVD P... YYY M POLICY EFF ' (MOLICYYEXP Y1rYY LIMITS A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007005500 01/21/2020 01/21/2021 EACH OCCURRENCE $1,000,000 CLAIMS- � OCCUR 2:58 PM EDT 12:01 AM MADE DAMAGE TO RENTED PREMISES (Ea Occurrence) $1,000,000 MED EXP (Any one person) Excluded PERSONAL & ADV INJURY Excluded ~^ N GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: (PRODUCTS—COMP/OPAGG $1,000,000 . POLICY ❑ PRO ❑ LOC JECT PROFESSIONAL LIABILITY OTHER: LEGAL LAB TO PARTICIPANTS $1,000,000 _3A AUTOMOBILE LIABILITY COMBcJEn SINGLE LIMIT �(Ea accident) ANY AUTO BODILY INJURY (Per person) OWNED AUTOS SCHEDULED BODILY INJURY (Per accident) ONLY HIRED AUTOS NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LB IJ CLAIMS -MADE AGGREGATE SLIA DED I ITRETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ Y / N E.L. EACH ACCIDENT EXECUTIVE OFFICER/MEMBER t"-""'""") I E.L, DISEASE -6^, EMPLOYEE EXCLUDED? (Mandatory in NH) I�� If yes, describe under DESCRIPTION E.L. DISEASE— POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007005500 01/21/2020 01/21/2021 PRIMARY MEDICAL $5,000 2:58 PM EDT 12:01 AM EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks SclryAqle, may be attached if more space is required) Type of Group: DJ's/KJ's, Musicians, singers or vocalists, Non -touring bands (tribute, wedding, garage); Music Genre: Country, Oldies, Pop/soft rock; Type of Venue: Auditoriums, Nightclubs, Outdoor venues The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. The City of EI Segundo, it's officers, officials, employees, agents and volunteers are named additional insurance of the additional insured; and wary r of subrogation applies as respect to workers comp as required by written contract, per endorsements attached. CERTIFICATE HOLDER CANCELLATION The EI Segundo,350 iSt90245 �THE EXPPIRCAETION DATE TESCRIBED POLICIES BE CANCELLED BEFORE YSegundo HEREOF, NOTICE WILL BE DELIVERED IN POLICY PROVISIONS. (Event Organizer) AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S. events and activities. ** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000007005500 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured. Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply. Additional Insured: The City of EI Segundo, its officers, officials, employees, agents and volunteers 350 Main St. EI Segundo, CA 90245 Named Insured: SMAX Entertainment CP# 1145 Effective Dates: 02/26/2020 to 01/21/2021 SRPG8018 09/08 POLICY NUMBER: 6BRPG0000007005500 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: The City of EI Segundo, its officers, officials, employees, agents and volunteers 350 Main St. EI Segundo, CA 90245 Named Insured: SMAX Entertainment CP# 1145 Effective Dates: 02/26/2020 to 01/21/2021 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 ©insurance Services Office, Inc., 2008 Page 1 of 1 O � = mm O �� a) M � 22 12; < fn (1) U) �n mD�� >C;)0 0D O, C -G1 z rn m �CM0� coots>O O 9 — �m r 0 m cn z -4 M y C z 00 � < n m z ���0 n M I2 > `, C) m p IF)"' ' � n in 0 � � moam z 0w < C- M h M ��""�o -.im p0 O CA m z m =' '< c► C7 w O 0 0 rmbo 24 Co -n i WnC: Colo > O ��un CLn O toO O Ol �4 3 O O W mNowI 6*0� V A O WAO z m 0 O, O w 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 rploy any person in any manner so a to b ome subject to the workers' compensation laws of California, and agree that, if I should become subje to t workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those o i " ns o e agreement will automatically become void. Signature of Applicant -- Date 'Veno Print Name Christian Sirnmon ' Agreement for:x Dated: 3-42 a Reviewed by: .�