Loading...
PROOF OF INSURANCE (2022 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 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 C N A LibertyUnited Insurance Services Inc NAME: Sam Muradyan � PHONE FAX 704 S Victory Blvd, Suite 204 E-MA Np XI 8187618888 fAIcNol. 868 5688 Burbank, CA 91502 ADDRESS: Sam@libertyunitedinsurance.com License #: OF89841 INSURER(S) AFFORDING COVERAGE NAIL p INSURED INSURERB: Ceiatnsitipy�, ..,, „_... -..e, Elite Special Events, Inc INSURERC: 11278 Los Alamitos Boulevard #101 INSURERDt Los Alamitos, CA 90720 INsuRERE INSURER F � COVERAGES CERTIFICATE NUMBER: 00001977-279009 REVISION NUMBER: 281 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 CONTRACTOR 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, YLTR. ADCiN.. SN.NBR'. ....POLICY POLIC I TYPE OF INSURANCE NUMBER Lt'R ......L"'In"t�.' � IMMIDU' �"YYY -PIO 7D YYY�" LIMITS A COM4MERCIAL GEE NERAIL LIABILITY Y Y ZISMB1499 o5io7no21 05/07/2022 EACHOCCURRENCE 000 fd`RtNtf� a Fry �1�300 000 „ C N91rMADE , OCCUR pia... . ''. MED EXP (Any one person} '. S 1,000,000 G::N'I.AGC Rlla AIEI IN11T AI IIPLJEF. ER' GENERAL AGGREGATE S 2,000,000 J _ LOC.; I PRODUCTS COMPIOPAGG S 2,000,000 0..1.L.IEER. S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT {F_p,acadeni) S ryry , ... .®.__. .. „ .........,,® „ II ANY AUTO ',, BODILY INJURY (Per person) S OWNED ITITIT SCHEDULED .. .. cide BODILY INJURY (Per acccident} , 9 AUTOS ONLY AUTOS ,e .,.,.,.,.,., . .— .... ....... HIRED NON -OWNED P I �:YI Y R7"v' Y1AIGNAGF S ..,..; AUTOS ONLY AUTOS ONLY LI'G�.i da ,idvrq) S OCCUR UMBRELLA LABH'"LA '., EACH OCCURRENCE 'S EXCESS LIAB CIMS-MADE'. AGG RE'.G AC E $ �® ,..... .ee. DED RETENTION S S ._. _ON ' WORKERS COMPENSATION �U.._.. PER Thi. ................._ AND EMPLOYERS' LIABILITY YIN STATUTE...... ER ANY PROPRIETORfPARTNERIEXECUTIVE"- E L EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? E - NIA ......- ...... ...... '.. (Mandatory in NH) EL DISEASE - EA EMPLOYEE. S If yes, describe under _.... ........__ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S B 'Accident/Medical ZISMB1499 05/07/2021 05/07/2022 $10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo, its officers, officials, employees and volunteers are listed as additional insureds as respects general liability and this insurance is primary and noncontributory with any other insurance of the additional insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE.. lz= -- ISMS) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on September 21, 2021 at 12:02PM POLICY #: ZISMB1499 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 Person or Organization: The City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability caused, in whole or in part, by your performance of ongoing operations for that insured. 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 written "insured contract", the insurance afforded to such additional insured will not be broaderthan that which you are required bythe written "insured contract" to provide for such additional insured. This coverage is provided on a primary and non-contributory basis a DATE (MM)DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/22/2021 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 rights to the certificate holder in lieu of such endorsement(s). '.. PRODUCER CONTACT Dave Warren NAME: Nielsen McAnany Insurance Services, Inc. PHONE (805) 379-8801 FAX (805) 204-4501 VIC No EV) tAIC. Na M MAIL 4165 E. Thousand Oaks Blvd ADDRESS: Suite 325 INSURER(S) AFFORDING COVERAGE NAIC # Westlake Village CA 91362 INSURERA: CallfOrnlaAuto Insurance 38342 w ...._..................... ..... .............. !INSURED INSURER B :. ELITE SPECIAL EVENTS, INC. INSURER C _............................................................_..,_ 404 N Sparks St P INSURER D :. INSURER E : Burbank CA 91506-1963 INSURER F: COVERAGES CERTIFICATE NUMBER: L:L21U22U61:Jli 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. INSR ADD gusq POLICY EFF POLICY EXP ..... LTR TYPE OF INSURANCE INSD WVD '', POLICY NUMBER MMIDD/YYYY Mtq/DR/YYYY w LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S UKU&TT== CLAIMS -MADE DOCCUR PREMISES (Ea occurrence) $ MED EXP (Any ane person) 5 PERSONAL&ADV INJURY S GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S PRO - ❑ 0 POLICY JET LOC PRODUCTS-COMP/OPAGG S OTHER- ' S AUTOMOBILE LIABILITY Co"MBINED ""IN4,4LE B, loll '', S 1;000,000 P Ea ar cadent' ANYAUTO BODILY INJURY (Per person) 5 A OWNED SCHEDULED BA040000023533 08/31/2021 08/31/2022 BODILY INJURY (Per accident) S AUTOS ONLY AUTOS HIREDA AN'hAla""E. 5.. AUTOS ONLY AUTOS ONLY ''., Per ncvdanl UMBRELLA LIAR OCCUR FAC:H OCCURRENCE S EXCESS LIAB _ CLAIMS -MADE .._ ......... AGGREGATE 5 BED RETENTION S WORKERS COMPENSATION PER OiH AND EMPLOYER S' LIABILITY YIN STATI.ITE FR ANY PROPRIETOR/PARTNER/EXECUTIVE '.... E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA """'""'"""""""""""""""" (Mandatory in NH) E l DISEASE EA EMPLOYEE S If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo, its officers, officials, employees and volunteers are listed as additional insured per attached MCA85100817-CA. Event date May 6, 2017, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE ElSegundo CA 90245 J. McAnany © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD IMPORTANT - THIS IS NOT A BILL. SEND NO MONEY UNLESS STATEMENT IS ENCLOSED. ' HOME OFFICE SAN FRANCISCO POLICY DECLARATIONS CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON. THIS INSURANCE IS EFFECTIVE FROM 12:01 A.M., PACIFIC STANDARD TIME CONTINUOUS POLICY9304403-21 8-26-21 TO 8-26-22 AND SHALL AUTOMATICALLY RENEW EACH 8-26 UNTIL CANCELLED ELITE SPECIAL EVENTS, INC DEPOSIT PREMIUM $0.00 11278 LOS ALAMITOS BLVD LOS ALAMITOS, CALIF 90720 MINIMUM PREMIUM $1,400.00 PREMIUM ADJUSTMENT PERIOD QUARTERLY N SP NAME OF EMPLOYER- ELITE SPECIAL EVENTS, INC (A CORP) TRADE NAMES- ELITE SPECIAL EVENTS, INC v LOCATIONS- 11278 LOS ALAMITOS B CYPRESS CA 90720 3958 1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA. 2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, $1,000,000 CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 08-26-21 TO 08-26-22 INTERIM PREMIUM BASE BILLING BASIS RATE RATE* 9095-1 EVENT MARKET, FESTIVAL OR TRADE SHOW 30000 9.24 9.99 OPERATION --ALL EMPLOYEES--N.O.C. ********BUREAU NOTE INFORMATION******** TED HOLCOMB P 50 % TOM MOORE CEO,S 50 % TOM MOORE T 0 $ FEIN 260747948 TOTAL ESTIMATED ANNUAL PREMIUM $2,997 COUNTERSIGNED AND ISSUED AT SAN FRANCISCO AUGUST 30, 2021 POLICY L PAGE 1 OF 3 SCIF FORM 10981A (REV.7-2014) (OVER PLEASE)