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PROOF OF INSURANCE (2021 - 2022) CLOSEDACCOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDU/YYYY) 1 05/25/2021 THIS CERTIFICATE IS 198UE5 A ATE 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. MP RTANT: If the certificate holder is an ADDITIONAL RED, the po icy(ies must have ADDITIONAI 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 endorsements . PRODUCER CONTACT NAME. Mass Merchandising Underwriting K&K Insurance Group, Inc. 800-328 2317 260-459 5502 1712 Magnavox Way ArC Na. E,,,, to/C, Nu): Fort Wayne, IN 46804 ADDRESS. entertainers@kandkinsurance,com INSURER(S) AFFORDING COVERAGE NAIC # _.._..._....�. INSURED .._....__............ ._.�._.... INSURER A: Nationwide Mutual Insurance Company 23787 SMAX Entertainment .__._............... _____.......... _ INSURER B: 46 vicolo della tuna ----""""""""""" ....""""------ INSURER C: henderson, NV 89011.............. .•••••••--- A Member of the Sports, Leisure & Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01954595 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. SR R LTR TYPE OF INSURANCE ADM UNSD SUBR D POLICY NUMBER ......... ......... MMIDD MMIDD LIMITS ............................................ _.._ A _.................. X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007507600 05/26/2021 05/26/2022 EACH OCCURRENCE $1,000,000 S OCCUR 12:01 AM EDT 12:01 AM DAM "'"""� $1,000,000 MADE PRE ISES Ea Occu rence MED EXP (Any one person) Excluded ......._.. PERSONAL & ADV INJURY .................. Excluded _— ..,..._................... GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP/OP AGG $1,000,000 R.O. R POLICY ❑ LOC BELT PROFESSIONAL LIABILITY OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY LIMIT`OMBINED SINGLE Ee. aCGldent. ANY AUTO BODILY INJURY (Per person) OWNED AUTOS ESCHEDULED OONLY AUTOSHIRENON-ONEDAUTOS ONLY.AUTOS ONLY Peracc�dant NOT PROVIDED WHILE IN HAWAII UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND NIA STATUTE OTHER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N E,L. EACH ACCIDENT EXECUTIVEOFFICER/MEMBER ................LO WWWWW E,L.. DISEASE —EA EMPLOYEE ...... EXCLUDED? (Mandatory in NH) E.L. DISEASE —POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007507600 05/26/2021 05/26/2022 PRIMARY MEDICAL $5,000 �—tl 12:01 AM EDT 12:01 AM _ ............ EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, 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. CERTIFICATE HOLDER CANCELLATION The City of El Segundo 350 Main St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE 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) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000007507600 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 Persons Or Or anjz,ation s The City of El Segundo 350 Main St. El Segundo, CA 90245 Named Insured: SMAX Entertainment 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 your acts or omissions or the acts or omissions of those acting 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 required by a contract or agreement, the insurance afforded 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 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; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 ©insurance Services Office, Inc., 2012 Page 1 of 1 06/02/21 For Roadside Assistance: 800-531-8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: • usaacom, • USAA's Mobile App, or • By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. Automobile Insurance Identification Card This identification card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident or upon a law enforcement officer's request Keep a copy of the ID card in your vehicle at all times. For your convenience, additional copies are available on usaa.com. FNV 1 Rev. 08-16 50804-0816_01 ----------------------------------------------------------------- 9NO Roderickalmorg umad Son Antonio. 'Texas 78M USAA° NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE COVERAGE MEET45,185, THIS EVIDENE OF INSURANCE HAS BEEN APPROVED BY THEREOUIREMENTS OF NEVADA COMMISSIONER OF IINVSIURED MNCE,OTOR VEHICLE FTHIS OR Of PRODUCTIO ON DEMAND NCE MUST BE CARRIED IN THE Name Policy Number CHRIS SIMMONS Effective Date 03/16/21 Expiration Date 09/16/21 46 VICOLO DELLA LUNA Year Make HENDERSON NV 89011-0112 2020 MERCEDES VehjcIi " p. Number USAA CASUALTY INSURANCE COMPANY 25968 CONTACT US: 210-531-USAA(8722) OR 800-531-USAA Additional copies available at usaacom 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # 91 certify that, in the performance of the work set forth in the agreement with the City of El 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 sub' ct t the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those/Wo ionX/oor the agreement will automatically become void. Signature of Applicant Print Name CHRISTAN Agreement for: SMAX Entertainment - 1 PSA Dated: 6-22-21 Reviewed by: Hank Lu DNO /21