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PROOF OF INSURANCE (2024 - 2025) CLOSED" as DATE (MMIDDIYYYY)
ACCN►,/ V CERTIFICATE OF LIABILITY INSURANCE
L - 05/02/2024
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).
PRODUCER 704 S Victory Blvd Suite 204 61676166 an
Liberty United Insurance Services, Inc PHONE 88 d;nsurance.comF
Sam ilbe �IIrroI _ ....._
r.y ��,��Il�a. E� ...._ ..� 1 CAac Ncr� 8882656889 .IT..
Burbank, CA 91502 ALA°REss _ M_m.� ....n^ .._ —
License #: OF89841 -URER—(, �_
1l 1s 1 . A Certain Underwriters at Llo d'sVERAGEof London NAIc n
INSURED INSURER. B
Elite Special Events, Inc INSURERC: _._
11278 Los Alamitos Boulevard #101 INSURER,D: ......
Los Alamitos, CA 90720 INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: 00001977-279009 REVISION NUMBER: 421
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. ..........
......... .....
........ ........-- LIMITS,
Iw6R - A_ D&3L wA1Bd � . POLICY EFF pDY EXIT
TR TYPE OF INSURANCE POLICY NUMBER MMIDD MMiIMI '00
COMMERCIALY Y ZISMB1499 03 05/07/2024 05/07/2025 EACH OCCURRENCE $ 1 000 000
A X �I OMM C L GENERAL
"""""'a • .� _..._
^LIABILITY
DAMAGE TO RENTED... — ..., ...""
CLAIMS-MADE OCCUR PREMISS; (Pa occurrence] $ 300,0��—
-- L........_
& ADV INJURY $ 1 PERSONA
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ M00,,000
C PRO -PRODUCTS COMP/OP AGG $ 2,000,000
",.. POLICY � JEDT LOC I ...�._—
�...
$
OTHER
COMBINED SINGLE LIMIT
$
AUTOMOBILE
LIABILITY
....... -
ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILYINJURY (Per accident)
$
AUTOS ONLY AUTOS.................-
HIRED NON -OWNED
IaROPERTY DAMAGE
$
AUTOS ONLY AUTOS ONLY
(Per au4nl) -.
—
$
UMBRELLA LIAB OCCUR
'. EACH OCCURRENCE ._
..
$ ,,,,,,,,, -,_____.—,
EXCESS LIAB CLAIMS -MADE
AGGREGATE
J.ETENTION
$
$
WORKERS COMPENSATION
PER OTH
STATUTE,,,, ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
E L EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N / A
E.L. DISEASE EA EMPLOYE
_ —
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
A
Accident/Medical
ZAH761 03
05/07/2024
05/07/2025
$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'.
II cz__� kt�_ SMS
©1988-2015 ACORD CORPORATION. All rights reserved.
Ar-non ,je i,2n4ainzt Tk-. ArnDn ..�...e �...� L..... �.e +e.c..4 ...�.�� s Amon o. + a ti., cone nGinoronon n+ �r1•A 7A \A
Policy Number: ZISMB1499 03
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:
City of EI Segundo, its officers, officials, employees and volunteers
350 Main Street
El Segundo, CA 90245
Any person or organization for whom the named insured has agreed by written "insured contract" to designate
as an additional insured subject to all provisions and limitations of this policy.
(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 broader than that which you are required by the written "insured contract' to
provide for such additional insured.
3. This coverage is provided on a primary and non-contributory basis.
POLICY NUMBER: ZISMB1499 03
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person or Organization:
City of El Segundo, its officers, officials, employees and volunteers
350 Main Street
El Segundo, CA 90245
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 we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract with that person
or organization and included in the "products -
completed operations hazard". This waiver applies
only to the person or organization shown in the
Schedule above.
CG 24 04 05 09 Insurance Services Office, Inc., 2008 Page 1 of 1
0 DATE (MMIDD/YYYY)
Ate" CERTIFICATE OF LIABILITY INSURANCE
04/05/2024
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).
PRODUCER CONTACT Jim McAnany
NAME:
PHONE 805 379-8805 FAX
(805) 204-4501
Nielsen McAnany Insurance Services, Inc. Aa Na E ( ) A)XC, N. ,
4165 E. Thousand Oaks Blvd N"AIL
_ADDRESS.
Suite 325 INSURER(S) AFFORDING COVERAGE NAIC #
Westlake Village CA 91362 INSURERA: California Auto Insurance 38342
............
INSURED INSURER B
ELITE SPECIAL EVENTS, INC. INSURER C
11551 Weatherby Rd INSURER D
INSURER E :
Los Alamitos CA 90720-3846 1 INSURER F
COVERAGES CERTIFICATE NUMBER: CL2392209782 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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 ADDL, 'DBROLICY'E OLI EXP LIMITS
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MMIDD/YYYY) ......••t
i
COMMERCIAL GENERAL LIABILITY EACH OCE $
Mit7
CLAIMS -MADE OCCUR PRENII.SErence. $
MED EXPerson) $
PERSONJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PJECROT LOC PRODUCTS - COMP/OP AGG $
OTHER:
AUTOMOBILE LIABILITY COMMNE'D SINGLE. LIMIT $ 1,000,000
Ea �csldatrikY �•
ANY AUTO BODILY INJURY (Per person) $
........
A OWNED X SCHEDULED BA040000023533 08/31/2023 08/31/2024 BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
✓. HIRED X NON -OWNED PROPER "YDAM.AGE $
AUTOS ONLY AUTOS ONLY Pu.a�ucrmitE�sx�ti
......... _ .........
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE AGGREGATE $
m
DED RETENTION $ $
WORKERS COMPENSATION PER .._ ER
STATUTE ER
AND EMPLOYERS' LIABILITY YIN •_
ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L. EACH ACCIDENT $
'.OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E.L.. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L.. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may attached it more space is required)
City of El Segundo, its officials, and employees are additional insured per attached MCA85100817-CA
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.
401 Sheldon 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
,/A MERCURY INSURANCE
Business Auto Broadening Endorsement
Nc py Acquired or p:::ormed I:::::rndty (Broad Form Named Insured) —Adds, as an insured, any newly
acquired or formed entity provided the insured owns at least 50% of that entity and it is formed
during the policy period. The maximum period is 180 days.
Prim ry and Worn-Coil°ntrilbu Cory if Regt..aprn: d by Contras — We will not seek contribution from any
other insurance available under specific conditions.
irrnpoyees as Ilrnsureds — An employee becomes an insured while using a covered auto that the
insured does not own, hire or borrow.
utorrna tic Additional Iinsured —Any person or organization that the insured is required to include
as an additional insured based on a contract or agreement that is executed prior to the injury or
damage.
Employee IKred Auto — An employee is an insured when operating an auto that is hired or rented
in the employee's name while on company business.
Supplementary Payments — Bail bonds coverage is increased to $3,000. Reasonable expenses
and loss of earnings, up to $500 per day, incurred by the insured are covered.
Fellow Employee Coverage — The exclusion has been removed.
Additkn)na..Fra n portatiorn I xpe nse — We will pay up to $50 per day, maximum is $1,000, for
temporary transportation expense resulting from the total theft of a covered auto.
I fired Auto Physical IDarrnage Coverage — If you have Hired Auto Liability coverage, and you carry
physical damage coverage for any of your autos, we will extend coverage for Hired Auto Physical
Damage to a limit of $50,000, subject to a $500 deductible.
Accidental Airbag Deployrune,rnl — We removed the exclusion, providing coverage for airbag
deployment that is accidental.
I....rnanCp.....ease Gap — Coverage for the unpaid amount due on the lease or loan has been added if
there is a total loss of an auto insured under this policy.
Glass li epar I::)edu ctible Waiver — We will waive the deductible if glass is repaired rather than
replaced.
rwo or Moi� DeducfilUes — If two or more policies or coverage forms from the company apply to
the same accident, only one deductible will be applied.
Arrn ruled I)uAes in the Event of Ac6deint, Claim, Suit or I....oss — The insured must notify us of an
accident as soon as possible.
Waiver of Su broga icon — We waive our right of recovery against others if the insured has executed
a written agreement prior to the accident or loss.
Unintentional IEriror, Omission, or Faipu.ar to U�sdllose II laaazirds — The policy will not be deemed
invalid if the insured unintentionally omits, errs or fails to disclose a hazard.
irr PIOYE;c p fired Auto - If the employee hires or rents a vehicle with permission of the insured,
Hired Auto Physical Damage applies.
lHired Auto - Coverage Gcrirlitory — Coverage applies anywhere in the world if an auto is leased,
hired, rented or borrowed without a driver for a period of 30 days or less, and the insured's
responsibility to pay for damages is determined in a suit brought in the US, its territories and
possessions, Puerto Rico, Canada or in a settlement that we agree to.
Bodily h-ujn..airy IF�ed fin aJ to Inc ,Ae IF�esOarnt Il crntlarngUisll'i — Bodily Injury includes mental
anguish.
CA, AZ, TX, OK, GA 10-16
MCA85100817-CA
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:
L__) 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 #
(f 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 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 r--i
Agreement for:Upt
Dated:
Reviewed by: