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PROOF OF INSURANCE (2022 - 2023) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 04/04/2022 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 endorsements . PRODUCER CON ei MM — Bands & Performing Groups K&K Insurance Group, Inc, y/c Egl 800-328-2317 {g/1; 260-459 5502 1712 Magnavox Way '&,N — Fort Wayne, IN 46804 ADDRESS. entertainers@kandkinsurance.com ^ CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC If INSURED ,.m INSURER A: Markel Insurance Company SMAXEntertainment INSURER B:.............................................._........................................................._............................................................................................,,,,� 46 VICOIo Bella luna ....................................................................................................................��..�.�.�.�.�.��.��.�..�,,,,,,_. henderson, NV 89011 INSURER- C ....... —, A Member of the Sports, Leisure & Entertainment RPG INSURER D: INSURER E: .�F.�.....��.�.�...�......._....��........�._....................�_.���.............................�.......�.......��......� �.�.����...........��......� INSURER COVERAGES CERTIFICATE NUMBER: W02143904 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. INS LTR. TYPE OF INSURANCE..... .,.. NSD WVD POLICY NUMBER (MwMIDDw MMIDD/YYYY ......................................................LIMITS 1._...L ................. ''.. A X COMMERCIAL GENERAL LIABILITY X IMIRPGOOOOOD0019600 05/27/2022 05/27/2023 EACH OCCURRENCE $1,000,000 CLAIMS X OCCUR 12:01 AM EDT 12:01 AM-igmArI.- f 5 $1,000,000 MADE PREMISES (Ea Occurrence) ME: iu EXP (Any one person) Excluded W......._............... PERSONAL &ADV INJURY..................._..Excluded.. �........................ . .................. ................ GENERAL AGGREGATE $5,000,000 C:,EN'IL AGORF::GA"IT::. ILIMI"r APF'ILIE::.S I:'E::.R: PRODUCT.S....._COMPIOP.a.....�._...,._............�.......�.........1............... 0 aO $1,000,000 c POLICY I ..� �� �'� C..f1G1 ., ... SSIOIVAI I IArIIV EVV C'C2Cil C........................................... .... ..,_,,.. .,,,,,�,,,.,....... .... --.. OTHER. LI:::G'AI.. LIAR 10 PAR CJPA.INTS $1,000,000 AUTOMOBILE LIABILITY .„(Ea accident ANY AUTO BODILY I IN,.IIJRY (I'er too son) OVIfNED AUTOS r"I it 1:)I.11l r:[:) BODILY INJI IRY (I'cr accided.) ONLY AIJI OS HIRED NON OWNED 7015�FtF YY IDA" I'A . AUTOS ONLY AV h I'OS ONLY (Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE. AGGREGATE DE.D RETENTION WORKERS COMPENSATION AND N/A r' OTHER EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ YIN E.L EACH ACCIDENT EXECUTIVE OFFICER/MEMBER """"" "' ""'°"'"' E.LDISEASE ASE -EA EMPLOYEE. E EXCLUDED? (Mandatory in NH) . If es, describe under DESCRIPTION Y E,L DISEASE— POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS M1 RPGOOOD000019600 05/27/2022 05/27/2023 PRIMARY MEDICAL. $5,000 12:01 AM EDT 12:01 AM EXCESS MEDICAL._.ITITITmmmmmmmmmmmm '. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Type of Group: Celebrity look-alikes, 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 SHOUID ANY N THE ABOVEDESCRIBED O C E E CANCELLED BEF RE 350 Main St, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Ih -1 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) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MlRPG0000000019600 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Organization(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 rn W W cc 1� �Wii T9 Wo CUnD N .q N �N¢ ch IZ N N N cmZ N V� q CM j J C O O W 1A � CO) E 23 G go W O v p S CD SN W WZO ~ O " o Q O > CC -a� cm x ON t� d oto W W ram^ O-Q Z$ Z Qa W gg� � O N WdWLU U a^D LLJ W % Z W dz N C) Z N Q Q cc W�— ; Z� 5 �f o=fig Z �' a WWI Clo wZ O0 Q N , En >999 9 U oW 0 0zzz E� >w O Zn v2 D U 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 Policy Number Expiration Date Name of Agent Phone # I 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 suet t# the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thosero ion or the agreement will automatically become void. Signature of Applicant Print Name CHRISTAN Agreement for: Dated: Reviewed b Y= Da`'t/e1 /21