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PROOF OF INSURANCE (2022 - 2022) CLOSEDDATE (MMIDDIYYYY)
ACTOR" CERTIFICATE OF LIABILITY INSURANCE
Ill 1 1 /21 /2022
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 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
NAME., .Amy Kwan
""'
TIB Transportation Ins Brokers PHONE FAX
425 West Broadway, Suite 300 IA�+��,Ftg, 818-246 2800 t�,f 818 246 4690
Glendale CA 91204 ADDRESS: akwan@tibinsurance.com
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.,L.------ ................. ....... ....... ...,...,.,..... ..... ..�,AObtl. t l "I4,. .. ,...,.,.,. ...,......... ....,....,.,.,., ..............POLICY EF1= POLICY EXf.....„ .................. ,..................,......
.... ....,......,
LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDD/YYYY I LIMITS
A
CLAIMS-MADE XX COMMERCIAL GENERAL .
�..,..
----- ....,.LIABILITY GL15B100#i9 8/31/2021 BI31/2022 IACH OCCURRENCE $ 5006 000
AMAu"LYIiRLN�Et1 ��
occuR y PRI�M!S,, .S occyT.q Se) $100 00.°..,,
.., e .......... ...... ..... ..... ......... .... .....
MED EXP (Any one person) $ 5,000
,...,. ,.... .m_ ...�. �.... w
''. '..
'.. PERSONAL & ADV INJURY 5 5.000,000
�
GENLAGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE S 5 000 000
%(....,
.,
POLICY .ECT LOC
PRODUCTS.,,.,,COMP/OP,AGG ..5....,_ ....... ...... .
1 GOTHEk
5
A AUTOMOBILE LIABILITY BA157040#19
8/31/2021 3/31/2022 C'OM 31 NF D.SINGLE L➢uM �
ANY AUTO
BODILY INJURY (Per person) S
ALL OWNED X SCHEDULED
' BODILY INJURY (Per accident) $
. AUTOS - AUTOS
X NON -OWNED
..... ........... .. ................. .. ......
CPER d'D.� S
HIREDAUTOS X .
E RT"AMA
- .......,.,.,_ ...,.,_AUTOS
..� ---------
UMBRELLA LIAB 1 OCCUR I
I EACH OCCURRENCE $
,AGGREGATE
EXCESS LAB CLAIMS -MADE]
'... $
---.
DED RETENTIONS
WORKERS COMPENSATION �
PER OTH
-AND EMPLOYERS' LIABILITY YI N j
E„R .A
'ANY PROPRIETOR/PARTNER/EXECUTIVE
` E L EACH ACCIDENT I $
1 OFFICER/MEMBER EXCLUDED? ❑] N / A
"
`(Mandatoryin NH)
-, E.L. DISEASE - EA EMPLOYEE; $
# If yes, describe under
I DESCRIPTION OF OPERATIONS below '..
'.. E.L. DISEASE - POLICY LIMIT 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, and volunteers are included as additional insured but only to the extent that the certificate
holder is held liable for the conduct of the named insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo
3501 Main St
El Segundo CA 90425 AUTHORIZED REPRESENTATIVE
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: GL156100#19
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED DULL PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following;,
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Oraanization(s) Location(s) Of Covered Operations
City of El Segundo Parks & Recreation
350 Main Street Room 5
El Segundo, CA 90245
u Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section 11 — Who Is An Insured is amended to B
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 acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
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.
With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply 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
completed; 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.
CG 20 10 04 13 © 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; or
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.
Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 ❑
POLICY NUMBER:GL156100#19
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):
CITY OF EL SEGUNDO PARKS & RECREATION
350 MAIN STREET ROOM 5
EL SEGUNDO, CA 90245
U 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 0 Insurance Services Office, Inc., 2018 Page 1 of 1
ACC 10/7/2
CERTIFICATE OF LIABILITY INSURANCE DATDIYYIY)
0/7/2021
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 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 CONTNAMEAC7 rjhen A(aitleS an
TIB Transportation Ins Brokers PHONE FAX �
425 West Broadway, Suite 400 (�p,r�a�>Gt) 818 246 2800 (AIo„No)18-26-4fa�0
� m
Glendale CA 91204 ADDRE'ss oatanesyan@libinsuranpe.comp
.�....... eea INSFFORDING COVERAGE NAIC #„
M w, .... „ ,,.....--, ,,
INSURER A: Republic Indem Co of America 22179
INSURED INLAN-1 INSURER B :
Inland Empire Stages Ltd.
9567 Eighth Street INSURER C
Rancho Cucamonga CA 91730-4504 IN SURE RD:
INSURER E
k1UVtKAUC0 Llrm I IrII,A I C ryUIVIDCR: IONtr4 t1:A;1t5 RCV IalUltl IYUIVIDCR;
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.
ILTR .... .....i ci SU�IMt.. ....,,,,. .POLICY NUMBER .M.&I.0 YEFF ,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,.,.,.,, .
TYPE OF INSURANCE F k IOM fOCt7Y EXP LIMITS
PYYYY
I = COMMERCIAL GENERAL LIABILITY 1 1 I EACH OCCURRENCE = S
CLAIMS -MADE , OCCUR PP�Gr�l(1IC - F��MI�I �Cdrrt;�a,r�umP3l S
MED EXP (Any one person)
S
'... '....
'.... PERSONAL & ADV INJURY
S
GEN'L AGGREGATE LIMIT APPLIES PER 1
GENERAL AGGREGATE
,.
...::.
POLICYPRE. JECI"
._
LUC
!. PRODUCTS COMP/OP AGG
S
OTHER:
AUTOMOBILE LIABILITY
('OMB1NCD SMK)Lc Lltu I
S
'...... ANY AUTO
'......
� BODILY INJURY (Per person)
$
ALL OWNED j
SCHEDULED
BODILY INJURY (Per accident)
S
AUTOS
1 ......,.
NON -OWNED
k'I'R'L}PEF'1'" CIAPo@A,ti�'
-
. „.,.,,,„,! HIRED AUTOS „ .
J _..
- AUTOS
S
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE1 AGGREGATE S
DED l I RETENTION S $
A WORKERS COMPENSATION I Y 15669020 10/1/2021 1011/2022 X PTATU,T,F„ � HRH
AND EMPLOYERS' LIABILITY
Y" 1N
ANY PROPRIETOR/PARTNER/EXECUTIVE j�; E.L EACH ACCIDENT S 1 DOD 000
(Mandatory in NH) "°"°"'"""°"i E L DISEASE - EA EMPLOYEE ..... ----
.OFFICER/MEMBER EXCLUDED? Y N I A
OYEE S 1 000 D00
If yes, describe under 1-u R mm"
' nFRCRIPTION OF OPFRATIONR helnW E L DISEASE - POLICY LIMIT S 1,000 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Officer Exclusion Applies - Curtis Basey, Nicole Basey
L;t_K I It-IUA I t HL)LUtK
City of El Segundo
Recreation and Parks Department
401 Sheldon St
El Segundo CA 90245
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
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 04-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
. ... _....0................
. _._.
State Person or Organization Job Description
California City of El Segundo Operations of insured.
Recreation and Parks
Department
401 Sheldon St
El Segundo, CA 90245
The premium charge for this endorsement shall be $50. This charge will be billed at the final audit.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated,
Republic Indemnity Company of America
Company Number ___.... 19739 � .... ✓���
Insured Inland Empire Stages Ltd (A Corp)
Policy Number 156690-20
Endorsement Number 7
Endorsement Effective October 01, 2021
__ . ......._. _._ ._�...._
Printed On October 06, 2021
Countersigned b
WC 00 03 13 Insured Copy
(Ed. 04-84)