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PROOF OF INSURANCE (2024 - 2025) CLOSEDDATE (MWDDNYYY) Acc?)?" CERTIFICATE OF LIABILITY INSURANCE L 1 07/19/2024 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 Will MadduX NAMEL..�.-_ _. ... W..,.,.,... ..,. East Main Street Insurance Services, Inc. 'PHONE (530) 477 6521 No ventill 1per.com Will Maddux 14FAg info @ c>E PO BOX 1298 .. mmITITINSURER(S� AFFORDING COVERAGEmmmmmmm NAI mIT . Grass Valley CA 95945 INSURER A: Evanston Insurance Company 35378 INSURED INSURER B LARRY NUTTER INSURER D : _..................m .... 5572 Laure ton Ave INSURER E : ......._.........._....... � �...._._ ...........-.� .�.�.__..�....� Garden Grove CA 92845 INSURERF: r. rrL•�.xcrr��r• rcoTlcrr ATc NIIIaAGCQ• RFVICICIN NIHMRFR^ 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 YWWWWW WWWWWWWWWWWWWWWTYPEOFINSURANCE .....__ �Ull POLICYNUMBER--..._ frPObLMY6"4f"Y'mITM'IfDt7FYYfF POLICY YY. LIMITS X.. COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 ..... CLAIMS -MADE OCCUR FXI. A�"f0�11'LIL`"� PREh�iIE;a. dra%laaar IMran fire) ., .:.... ............ ..... $ 1,000,000 Host Liquor Liability MED EXP (Anyone person) $ 5,000 A Retail Liquor Liability Y N 3DS5475-M3482726 08/06/2024 08/07/2024 PERSONAL & ADV INJURY $ 1,000,000 _. .... GEN'L ......... AGGREGATE LIMIT APPLIES PER: 12:01 AM 12:01 AM GENERAL GENE ......._........... $ 2,000,000 ....._ PRO- POLICY JPC1° � LOC PRODUCTS - COMP/OP AGG ...._ ''... $ 2,000,000 m$mm Deductible None OTHER: AUTOMOBILE LIABILITY COMSINE,O SINGLE LIMIT $ ANY AUTO BODILY INJURY (Per person) $ .... OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS . HIRED NON -OWNED PROPE.RG"Y DAMAGE. •-• $ AUTOS ONLY AUTOS ONLY _ JRR alyc"d„tactE •••. ••••�-- . UMBRELLA LIAB OCCUR CCURRENCE EACH 0........._ $ .. EXCESS LIAB CLAIMS -MADE.. ....,�....._.� AGGREGATE w,._.�._......�.- $ DED ' RETENTION.$ WORKERS COMPENSATION ER OTH- STATIJ7E.. ER AND EMPLOYERS' LIABILITY Y/ N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A _ .L. EACH ACCIDENT E (Mandatory in NH) E• L. DISEASE EA EMPLOYEE .mm. �............... $ •••� ........W If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 7 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: 200, Event Type: Performer at Event(No Heavy Metal, Punk, Rap, Hip Hop or Hard Rock). CFRTIFIf^_ATF Mill IIFR CANCELLATION THE CITY OF EL SEGUNDO, IT'S OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS 350 Main St. ElSegundo 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 f V 79SS-ZU1 S AGUKU I;UKt UKA I R /1V. Ali rlgnis reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY gill POLICY NUMBER: 3DS5475-M3482726 IRKEV 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, IT'S OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS 350 Main St. El Segundo, CA 90245 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 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. MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. 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 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. ( Mb le INSURANCE CARD state Farm Mutual Automobile Insurance Company PO Box 2358 Bloomington IL 61702-2388 IN UAEa NUTTER, LARRY MU L L POLICY NUMBER 568 2482-A11-750 EFFECTIVE YID 1900 BAKE MERCEDES JUL 11 2024 TO JAN 11 2025 MODEL 300 VI N 4 AGENT INAE PARK INSURANCE AGC Y INC 241 £-A75 UNE �31 %372-6688 NAIG 25178 COVERAJ PVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. COVERAGES A C D100 U Q1 SEE REVERSE RIDE FOR AN EXPLANATION. III r The premium on the expiring policy term was based on 8,200 miles per year. The premium on the renewal policy term was based on 8,200 miles per year. Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and DRIVER INFORMATION Principal Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your model. In addition, we review the comprehensive, collision, bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. premium may be influenced by the information shown for these drivers. COVERAGE AND LIMITS See your policyforanexplanation ofthese coverages. A Liability Bodily Injury 250,000/500,000 Property Damage 100.000 $242.96 C Medical Payments 1,000 $7.37 D 100 Deductible Comprehensive $54.44 U Uninsured Motor Vehicle Bodily Injury 250,000/500,000 $65.02 U1 Uninsured Motor Vehicle PropenX Damage $7,00 Amount Dux $ 76J9 If any coverage you carry is changed to give broader protection with no additional premium charge, we will give D IS CO U N TS These adjustments have already been applied to your premium. Line Multicar Driving Safety Record California Good Driver Total Discounts Other Available Discount(s) You may be eligible for additional discounts Seethe enclosed insert for more information. Mature Driver you the broader protection without issuing a new policy, starting on the date we adopt the broader protection. Policy Number: 566 2452-Al 1-750 Page number 3 of 5 Prepared May 20, 2024 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION -7 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 loy any person in any manner so as to orne subject to the workers' compensation laws of California, and agree that, if I should become subject to tbeworkers' c 'rper ation provisions of Labor Code § 3700 1 must immediately comply with those provisio n the agreem "� t�atically become void. Signature of ApplicantD ate Print Name ` Agreement for: Dated. Reviewed by: