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PROOF OF INSURANCE (2024) CLOSEDDATE (MMIDDrr" CERTIFICATE OF LIABILITY INSURANCE 04/01/2024 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). CONT PRODUCER eewan I ee Agency ncT Zaln Jeewan'ee Insurance A enc PH,OwE (408) 217-6787 408 997 7890 ,,.La 1494 Hamilton Ave Suite 103 q% 8 ...p c., _..._.__ E-MAIL San Jose CA 95125 nr,��,�c�. sulaDorl(o"�.onedavevent.com Arch Insurance INSURED Tanya Taylor Black in Mayberry 755 SHELDON ST EL SEGUNDO CA 90245 COVERAGES CERTIFICATE NUMBER: 1002225323 REVISION NUMBER: 11150 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. 1 5R TYPE OF INSURANCE . b,'uff ppUCYNUMBER MMODnEFF POUC7'YY..YI ^IT LIMITS A • COMMERCIAL GENERAL LIABILITY r 06/1312024 06116/2024 SNCGL4643100 EACH OCCURRENCE $ 1,000,000 ' 't'' OAM"A13t'1163� 00 1100010 CLAIMS -MADE OCCUR pR MS rv$ � * cF�..? Host li our MED EXP (An one arson) S 5,000 , _PERSONAL 8 ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 5,000,000 POLICYK] JPFO U LOC PRODUCTS -COMPIOPAGG $ 5,000,000 , • OTHER: • Deductible s0 AUTOMOBILE LIABILITY (O COMBINED ISINGLE LIMIT ^ $ AN:Y'AUTO BODILY INJURY (Per person) S OWNED LY SCHEDULED AUTOS ONAUTOS BODILY INJURY (Per acERddent)' $ HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY _(P¢r acrJdent7 UMBRELLAUAB OCCUR EACH OCCURRENCE S AGGREGATE $ EXCESS LWB CLAIMS -MADE DEL? RETE.:NTION $ $ �- WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIASILI Y YIN ff_AEVEF_.0 9li -"..... . 'ANYPROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT S 0NIA �.� nNEREXCLUDED? (Mandatory In DISEASE -EA EMPLOYEE... $ kIf yyes, ftsur bo underEL ."_.." DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is required) The Certificate Holder shall be an Additional Insured, but only with respect to the operations of the Named Insured, and subject to the provisions and limitations of Form CG 2026 Additional Insured - Designated Person or Organization, but only with respect to JUNETEENTH FESTIVAL from June 13, 2024 through June 16, 2024 THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS 35D Main Street, EL SEGUNDO CA 90245 are added as additional insured. CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS 350 Main Street 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. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software. www.FormsBoss.com (c) Impressive Publishing 000-208.i9T7 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 ATTORNEYS FEES. I affirm under penalty of pedury under the laws of California one of the following declarations: U I have and wilt 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. L_) 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 # 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 immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Date Print Name Agreement for: ibi ►-A a d mm Dated: 110 I Reviewed by: 10tM A PWVW�