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PROOF OF INSURANCE (2020 - 2020) CLOSEDC y DATEY)
AC40RV CERTIFICATE OF LIABILITY INSURANCE o2/25120201251zozD
THIS CERTIFICATE IS ISSUED ASA 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 V CONTACT Shelli Appling
X[,PI10NE'.
NAME:
Appling Insurance Services (562) 594-6893 F (562') 431-3685
10845 BLOOMFIELD STREET E°MAIL Sftefll( applcngmsuranee,net
ADDRESS:
_ GNSURERISI AFFORDING COVERAGE NAIC 0
LOS ALAMITOS CA 90720 I INSURERA : UNITED SPECIALTY INSURANCE COMPANY I 12537
INSURED I INSURERS: ........................ A
Hey Hey Entertainment LLC, Richard Woloski I INSURER 2 _
DBA: Hey Hey EntertainmentI INSURER D,
3441 Faust Ave. VVVY INBURERE:
Long Beach CA 90808 INSURER F:
COVERAGE'S CERTIFICATE NUMBER: CLI932701209 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 DESCRIBE^ HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C AIMS.
{au ... 5DBH, POd V"I�rr_.'.. POUCYEXP
INSD WVD LIMITS
LrR TYPE OF INSURANCE _ POLICY NUMBER PMWDD °YY1' IMM:MDNYYYY
W_
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
100,000
CAMOALWE WEU HEN I EU
® CLAIMS -MADE ❑X OCCUR PREMISES iEa c<cun,03W) S
MED EXP ( V one person) S 5,000
A Y USA -4255582 04/0912019 04/09/20201,000,000
PERSONALSADVINJURY $ .m..
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY 0 JEC F_� LOC I PRODUCTS-COMP10PAGG $ 2,000,000
I $ ._
OTHER
..A....Aw._..... .............................__,.,.,,,.......,......_,...,
AUTOMOBILE LIABILITY En ac NED SINGLE 'rJIMIIT cIderV $
mANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJ URY (Per accident) $
AUTOS ONLY AUTOS
WRtOP'ER'TY DAMPkGE
HIRED NON -OWNED $
AUTOS ONLY AUTOS ONLY I'Paa ;trciAenxi
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS -MADE AGGREGATE $
DED I Il RETENTION S ...............
WORKERS COMPENSATION T
AND EMPLOYERS'LWBILRV YIN I STA UTE I ERH
ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA E.L EACH ACCIDENT S
OFFICEWMEMBER EXCLUDED? Y
(Mandatory in NH) I E.L. DISEASE - EA EMPLOYEE $
_ If yes, describe under
DESCRIPTION OF OPERATION'S balm _ E,L DISEASE - POLICY UMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL
INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED WITH RESPECTS TO LIABILITY
EL SEGUNDO PUBLIC LIBRARY, 111 WEST MARIPOSAAVE„ EL SEGUNDO, CA 90245
10 Day Notice of Cancellation for non-payment of premium 1L___1
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
THE CITY OF EL SEGUNDO, PUBLIC LIBRARY ACCORDANCE WITH THE POLICY PROVISIONS.
ATTN. LIBRARY DIRECTOR
AUTHORIZED REPRESENTATIVE
111 W. MARIPOSAAVE.
ELSEGUNDO CA 90245
I n
©1968-2015 ACORD CORPORATION. All rights reserved.
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: USA -4255582
COMMERCIAL GENERAL LIABILITY
GG : 010 04:13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED 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)
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS,
EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS.
Location(s) Of Covered Operations 7
111 WEST MARIPOSA AVE.
EL SEGUNDO, CA 90245
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — 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:.
1. Your aots or omissions; or
2. The acts or omissions of those acting on'your
behalf;
in the performance of your ong,ping opertions for
the additional insured(s) at the location(s)
designated above.
Hnpvever:
1. The insurance afforded to such additional
insured only applies to the extent peanitted..by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
Will .not be broader then 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
additional insureds, the following additional
exclusions apply:
This insurance hoes n0t,.a0ply ;to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
c6m00te ; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
OGS 26 0 ht 11 © Insurance Services Office, Inc., 2012 Page 1 of 2
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
if coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance,
1. Required by the contract or agreement,
2. AvallA% under the applicable - ;im it"'
Insurance shown in the Declarations;
whichever. less-,. -
This endorsement shall not increase
applicable Limits of Insurance shown in
Declarations.
of
the
the
Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 20 10 041,
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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 El 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 E1 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 provisions or the agreement will automatically become void.
Signature of Applicant A -Jl� (44444: Date 2/21/2020
A9 reement for: � �, UOWO—
Dated*
Reviewed by: --c ta