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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, AINI'Alic aidw-d x"41 sil wow*l 31AW F,Mf AIvel LiciAl Bw6 CA 9108011-283:9 P, P F IS'414: Rle 's illif it''rit f 0 r1l 11 a In R fol LVAI.: KiEll V1 AR,u' MAKE ` tA III rif L 11 924 99,S74,41Z13114 Toy, Trod RaYA4 I 111 17, 1191 L11.1A]l VFH9f'i1F11)N",,; Fir 0,911s:1114 273WF REVOIEW09:111219 EYPIP'lli 111'41 Dill 013111SI20 ,Jil jell VI� III r E ii?rfa 11111'e, EN ...... ...... ji, All III -alto as 1 . ....... ill., =,Am�'i I , -,,:'TT UNN; IIIIINIM ly ,^" Alp i Mu;,: A. 1111A:,I.1�111�1 I W111 Ill 1-111--l'-, 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