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PROOF OF INSURANCE (2022 - 2022) CLOSEDDATE (MWDD/YYYY) AC"RV CERTIFICATE OF LIABILITY INSURANCE 11 /30/2021 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 10. 4 Will MadduX 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. .. TYPE OF INSURANCE ����,.... d. „_m..�„ INSii .,.,.,.,., .. ...... .. .. AODL SURR ,. _ 1C"OLgCY FFF PrOk.4GM E�RP LTR POLICY NUMBER I Mlt'/A.^DD/YYYY MNWDDrYYY LIMITS ..... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 i ® PREMIS Yt( (uir ,,., '.... 1 00,000 ,.....� CLAIMS -MADE OCCUR a o „REMISE-, aocurre occurrence) $ . .... Host Liquor Liability I MED EXP (Any one person) $ -5 000 A Retail Liquor Liability Y 13DS5472-M2979655 12/03/2021 j 12/04/2021 PERSONAL&ADV INJURY $ 1,000,000 ,111 GEN'L AGGREGATE LIMIT APPLIES PER: 12:01 AM 12:01 AM GENERAL AGGREGATE $ 2,000,000 POLICY PROP .CECu LOC I PRODUCTS -COMP/OP AGG $ 1,000,000 IJTFMER: Deductible $ 1,000 I AUTOMOBILE LIABILITY I C+OMEINEDSINGLE OWr I..$ )a6fld ,' ac�7adcn(). ANY AUTO ! BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS � BODILY INJURY (Per accident) $ 1 .HIRED NON -OWNED Po�diOPt'�T'Y'DAMF4.GF $ I AUTOS ONLY AUTOS ONLY i,.,gPuror uca�rdas�tCi !„_ ,„ i UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE '... AGGREGATE $ DEC) '€ € RETENTION $ f ........ " $ WORKERSCOMPENSATION ANDEMPLOYERS' LIABILITY j J PER OTH-- �„ STATUTE E;R Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE j I E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE -EA EMPLOYEE $ If yes, describe under� DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ I I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19, Attendance: 150, Event Type: Vendor at Event. The City of El Segundo, its officers, officials, employees, agents and volunteers are additional insured. CERTIFICATE HOLDER CANCELLATION The City of El Segundo 3501 Main St ElSegundo CA 90425 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 3DS5472-M2979655 MMIKE»'e 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 ization(s): The City of El Segundo, its officers, officials, employees, agents and volunteers 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. ------------------------------------------ IMPORTANT - IDENTIFICATION CARDS .STATE FARM CALIFORNIA /x I.M.W T KFRI MIIIInn19 n INSURANCE CARD = vencu FOR ifaoumiowuroRoewnwxeO r �M1F! Au1FInNY leamneF CalnRseY ,i"`isi�rikraw�n�nwam curt VOL 6610-AMICR IFFIIUIIYF ,spy s� Vx f= #t'.sF2 e d Ft4y 0.2€: a1R . ll4ea_s. FIB - =11e.wtlFw wewF�F. •r eerr -- -� --- --a lFpwlseetlew Fs.�wFw wOltl �� N.4i l..we � �� UIIhnYM W�Yw�eY KEEP A CARDIN YOUR CAR KEEP OUR CURRENT CARD pUNTIL THE EFFECTIVE DATE OF THIS CARD. owe aanor� eiR�MrON6 Gn0i D11A FMMUw oiRM�a Ri Rai F011�RrOKtIRKIi1ME1'IW IRMAkl oFIIYRRNWI IrooWFR wn a— 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 # VN ertify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not ploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should bec me subje to the workers' compensation provisions of Labor Code § 3700 1 must o' immediately comply }` erthe agreement will automatically become void. Signature of Appca Date Print Name Oh I Agreement for: ` ! Dated: i Reviewed by:I " `-�. m..