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PROOF OF INSURANCE (2021) CLOSEDDATE (MWDD/YYYY) ACC>RE► CERTIFICATE OF LIABILITY INSURANCE 06/22/2021 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(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 ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER NONTACT Will Maddux East Main Street Insurance Services, Inc. (53 PHONE 0 477-6521 FAX JAM Not. ........... -. (Arc, Nal .... E-MAIL nthelper.com Will Maddux AOQ ss....Info@theeve.... m ........ - PO Box 1298 _ INSURER(S) AFFORDING COVERAGE NAIC # Company 35378 Grass Valley .---__ CA 95945 . rr�suRER A Evanston Insurance - __, ___ _...-----__ ...... . INSURED iuca iRRR R AirballingLA _INSURER C _ Nicholas Cho IMSURER D .., --- ER LOS ANGELESINSUBIvd, Apt#304 CA 90019 INsuRERe F. ____ �.- ., __ ..... rnvconr-oc !`ICI2TICIf`ATlc KIIHURIIPQ• RFVISIC)N N11MRFR! - - - -- -- - -- - 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. ,. ..... .� -- _.- POIJCXNUMBER ... -..__ OLJCYEFF MMILl DD/Y XP,. ... .... ..-._ .-------- ..._ .... .... ............. TYPEOFINSURANCE INSRLIMITS �'.. C MMERCIAL GENERAL LIABILITY EACH OCCURRENCEA $ OO �. CLAIMS -MADE � OCCUR " S+nE'M' "NTk'O_. � ,_)?HgMLS T 4Ea orc,.crJrren-* $ 100,000 Host Liquor Liability MED EXP (And one person) A Retail Liquor Liability Y Y 3DS5472-M2644445 SEE BELOV SEE BELOV PERsoNAL&ADvwJURY '_$ $ 1,000,000 N L AGGREGATE LIMIT APPLIES PER: 12:01 AM 12:01 AM GENERAGGREGATE � $. 2OOO OOO �� POLICY PRO" - LOC GE ,CAL PRODUTS COMPIOP AGG $ 1 000 OO 0 1 oTItEw'a: � Deductible $ 1,000 AUTOMOBILE LIABILITY , "y OOMSINED SINGLE LIMIT En acuiderp � $.................. ......................... _. ANY AUTO BODILY INJURY Per erson ( person) $ OWNED SCHEDULED ' 1 BODILY INJURY (Per accadent) .... ...... $ AUTOS ONLY AUTOS HIRED NON -OWNED "" PROPERTY DAMAGF..� - AUTOS ONLY AUTOS ONLY �....f�!-r ticamlEa.pV,V _ $ ..... ,.,.,... -.. UMBRELLA LIAB Iy9 OCCUR EACH OCCURRENCE, ...__ -- 1((.. EXCESS LIiAB CLAIMS -MADE AGGREGATE $ _- - 4 DED 4 $ -RETENTION WORKERS COMPENSATION I PER H I STATUTE„I OE,RAND EMPLOYERS'LIABILITY Y/N E.L. EACH ACCIDENT --- $ OFFICER/MEMBEREXCLUDED? ❑ N / A �, ..... .... (Mandatory nANYPROPRIETNH)PARTNERIEXECUTIVE . EMP E.L.E L DISEAS LOYEE ....�,., ... $ .,.,. If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19 for the following dates: 07/10/2021, 07/11/2021, 07/12/2021, 07/13/2021, 07/14/2021, 07/15/2021, 07/19/2021, 07/20/2021, 07/21 /2021, 07/22/2021, 07/24/2021, 07/26/2021, 07/27/2021. 07/28/2021, 07/29/2021, 08/01 /2021, 08/02/2021, 08/03/2021, 08/04/2021, 08/05/2021, 08/06/2021, 08/07/2021, 08/08/2021, 08/09/2021, 08/10/2021, 08/11 /2021, 08/1212021, 08/13/2021, 08/14/2021, 08/15/2021, 08/1612021, 08/17/2021, 08/18/2021, 08/19/2021, 08/20/2021, 08/21 /2021, 08/22/2021, 08/23/2021, 08/24/2021, 08/25/2021, 08/26/2021, 08/27/2021, 08/28/2021, 08/29/2021, 09/04/2021, 09/05/2021, 09/11 /2021, 09/12/2021, 09/18/2021, 09/19/2021, 09/25/2021 & 09/26/2021. Attendance: 260, Event Type: Event Vendor. The City of El Segundo its officers, officials, employees, agents, and volunteers. 350 Main St ElSegundo CA 90245 9-q-f_111LVJ CI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE U 199S-ZU15 ACUHL) cUKPUHA I IUN. Ali rlgniS reserves. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY III POLICY NUMBER: 3DS5472-M2644445 MARKEV EVANSTON INSURANCE COMPANY 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 FORM SCHEDULE Name Of Additional Insured Person(s) Or Organ izati on (s): The City of El Segundo its officers, officials, employees, agents, and volunteers. 350 Main St El Segundo, CA 90245 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 of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by the acts or omissions of any insured listed under Paragraph 1. or 2. of Section II —Who Is An Insured: 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 contractor 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. All other terms and conditions remain unchanged. MEGL 2217 01 19 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER: 3DS5472-M2644445 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 0104 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 3DS5472-M2644445 COMMERCIAL GENERAL LIABILITY CG 24 0412 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following. - COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): The City of El Segundo its officers, officials, employees, agents, and volunteers. 350 Main St El Segundo, CA 90245 I 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 against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 0412 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 k / S ƒ § 6 A \ ID Xal 7z"N / 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 forthe 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 Policy Number Expiration Date Name of Agent Phone # 0 1 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 subject to the workers' compensation provisions of Labor Code § 3700 1 must day comply with those provn or the agreement will automatically become void.. une 28th Signatue of Applicant Date Print Name 2021 Agreement for: � -a. 6 1-� , Dated:�� Reviewed by: Hank Lu-Risk Mana er